Healthcare Provider Details

I. General information

NPI: 1558807107
Provider Name (Legal Business Name): CHARLOTTE NORDSTROM
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/06/2017
Last Update Date: 05/19/2023
Certification Date: 05/19/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

661 W 1ST ST STE G
TUSTIN CA
92780-2939
US

IV. Provider business mailing address

661 W 1ST ST
TUSTIN CA
92780-2939
US

V. Phone/Fax

Practice location:
  • Phone: 714-665-9890
  • Fax: 714-665-9891
Mailing address:
  • Phone: 800-597-7977
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number9500534
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: