Healthcare Provider Details

I. General information

NPI: 1861791923
Provider Name (Legal Business Name): LAURA ESTRADA RN/PHN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/15/2011
Last Update Date: 03/15/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11711 SAND CANYON RD
YUCAIPA CA
92399-1742
US

IV. Provider business mailing address

7917 SAN BENITO ST
HIGHLAND CA
92346-6352
US

V. Phone/Fax

Practice location:
  • Phone: 909-389-3272
  • Fax: 909-389-0772
Mailing address:
  • Phone: 909-389-3272
  • Fax: 909-389-0772

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WC1400X
TaxonomyCollege Health Registered Nurse
License Number538041
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: