MEDICARE: ELIZABETH PHELAN RN FNP-BC MSN

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	363LF0000X	Family Nurse Practitioner	RN 464512	CA

General Provider Information

NPI Number	:	1144604794
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	ELIZABETH PHELAN RN FNP-BC MSN

Provider Business Mailing Address
First Line	:	12 CORPORATE PLAZA DR STE 150
Second Line	:
City	:	NEWPORT BEACH
State	:	CA
Zip	:	92660-7921
Country	:	US
Telephone Number	:	949-244-6227
Fax Number	:

Provider Business Practice Location Address
First Line	:	2077 HARBOR BLVD
Second Line	:
City	:	COSTA MESA
State	:	CA
Zip	:	92627-2630
Country	:	US
Telephone Number	:	949-722-2510
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	07/14/2015
Last Update Date	:	07/14/2015

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