MEDICARE: CHELSEA BEATRICE DOUGLASS

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	363LP2300X	Primary Care Nurse Practitioner	95039300	CA

General Provider Information

NPI Number	:	1790615433
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	CHELSEA BEATRICE DOUGLASS

Provider Business Mailing Address
First Line	:	486 CYPRESS DR APT F
Second Line	:
City	:	LAGUNA BEACH
State	:	CA
Zip	:	92651-1641
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	486 CYPRESS DR APT F
Second Line	:
City	:	LAGUNA BEACH
State	:	CA
Zip	:	92651-1641
Country	:	US
Telephone Number	:	909-912-9863
Fax Number	:

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

Provider Enumeration Date	:	05/22/2026
Last Update Date	:	05/22/2026

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