=====================================================
General NPI Number Information
=====================================================
NPI Number | 1104937580
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | COLLEEN O'CONNOR CRNA
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/31/2006
-----------------------------------------------------
Last Update Date | 11/06/2015
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 29300 PORTOLA PKWY # A
-----------------------------------------------------
City | LAKE FOREST
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 92630-8718
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 949-716-2726
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 210 N TUSTIN AVE
-----------------------------------------------------
City | SANTA ANA
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 92705-3807
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 714-347-1000
-----------------------------------------------------
Fax | 714-647-1245
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 367500000X
-----------------------------------------------------
Taxonomy Name | Certified Registered Nurse Anesthetist
-----------------------------------------------------
License Number | 1116
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------