Healthcare Provider Details

I. General information

NPI: 1205265931
Provider Name (Legal Business Name): LORRAINE MAE DOMINICK WHNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/04/2013
Last Update Date: 11/04/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1310 SAN BERNARDINO RD
UPLAND CA
91786-4979
US

IV. Provider business mailing address

8735 MANDARIN AVE
ALTA LOMA CA
91701-3368
US

V. Phone/Fax

Practice location:
  • Phone: 909-579-0806
  • Fax: 909-579-1331
Mailing address:
  • Phone: 909-395-7146
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LX0001X
TaxonomyObstetrics & Gynecology Nurse Practitioner
License Number23698
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: