MEDICARE: MARY JEAN O'CONNOR N.P.

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	363L00000X	Nurse Practitioner	7588	CA

General Provider Information

NPI Number	:	1871515601
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MARY JEAN O'CONNOR N.P.

Provider Business Mailing Address
First Line	:	5700 CANOGA AVE
Second Line	:	SUITE 500
City	:	WOODLAND HILLS
State	:	CA
Zip	:	91367-6579
Country	:	US
Telephone Number	:	818-595-8100
Fax Number	:	818-595-8206

Provider Business Practice Location Address
First Line	:	364 OCEAN AVE
Second Line	:
City	:	LAGUNA BEACH
State	:	CA
Zip	:	92651-2322
Country	:	US
Telephone Number	:	949-557-0610
Fax Number	:	949-557-0611

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

Provider Enumeration Date	:	07/24/2006
Last Update Date	:	03/14/2019

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