Provider Demographics
NPI:1275960494
Name:CHANG, AUDREY WILLA (PNP)
Entity Type:Individual
Prefix:
First Name:AUDREY
Middle Name:WILLA
Last Name:CHANG
Suffix:
Gender:F
Credentials:PNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:24422 AVENIDA DE LA CARLOTA STE 300
Mailing Address - Street 2:
Mailing Address - City:LAGUNA HILLS
Mailing Address - State:CA
Mailing Address - Zip Code:92653-3628
Mailing Address - Country:US
Mailing Address - Phone:949-599-2434
Mailing Address - Fax:949-599-2430
Practice Address - Street 1:2071 SAN JOAQUIN HILLS RD
Practice Address - Street 2:
Practice Address - City:NEWPORT BEACH
Practice Address - State:CA
Practice Address - Zip Code:92660-6505
Practice Address - Country:US
Practice Address - Phone:949-759-1720
Practice Address - Fax:949-759-1442
Is Sole Proprietor?:No
Enumeration Date:2013-10-02
Last Update Date:2022-03-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA23514363LP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPediatrics