Healthcare Provider Details

I. General information

NPI: 1962945949
Provider Name (Legal Business Name): LINDSAY KELLY WILSON
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: LINDSAY KELLY ROMERO

II. Dates (important events)

Enumeration Date: 11/23/2016
Last Update Date: 11/14/2023
Certification Date: 11/14/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

15405 LANSDOWNE RD STE C
TUSTIN CA
92782-0201
US

IV. Provider business mailing address

400 N TUSTIN AVE STE 120
SANTA ANA CA
92705-3879
US

V. Phone/Fax

Practice location:
  • Phone: 714-258-7710
  • Fax:
Mailing address:
  • Phone: 949-683-7893
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code172V00000X
TaxonomyCommunity Health Worker
License Number
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: