=====================================================
General NPI Number Information
=====================================================
NPI Number | 1649425752
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | PATRICIA JOAN O'DONNELL NURSE PRACTITIONER
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/18/2008
-----------------------------------------------------
Last Update Date | 11/18/2008
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 31862 COAST HWY #115
-----------------------------------------------------
City | LAGUNA BEACH
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 92651
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 949-500-1351
-----------------------------------------------------
Fax | 949-315-3517
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 25501 CROWN VALLEY PKWY #379
-----------------------------------------------------
City | LADERA RANCH
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 92694-1195
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 949-365-0617
-----------------------------------------------------
Fax | 360-656-3288
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 363L00000X
-----------------------------------------------------
Taxonomy Name | Nurse Practitioner
-----------------------------------------------------
License Number | 155561
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 363L00000X
-----------------------------------------------------
Taxonomy Name | Nurse Practitioner
-----------------------------------------------------
License Number | CERTIFICATE 1636
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------