=====================================================
General NPI Number Information
=====================================================
NPI Number | 1245568724
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | LISETTE MACIAS NP
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/23/2009
-----------------------------------------------------
Last Update Date | 09/17/2016
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1 HOPE DR
-----------------------------------------------------
City | TUSTIN
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 92782-0221
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 714-247-0300
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 3019 CROYDEN BAY
-----------------------------------------------------
City | COSTA MESA
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 92626-6912
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 909-519-6737
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 163W00000X
-----------------------------------------------------
Taxonomy Name | Registered Nurse
-----------------------------------------------------
License Number | 748044
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 363LP0200X
-----------------------------------------------------
Taxonomy Name | Pediatric Nurse Practitioner
-----------------------------------------------------
License Number | 95004862
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------