Provider Demographics
NPI:1346603248
Name:DEWALT, LAUREN (AGNP)
Entity Type:Individual
Prefix:
First Name:LAUREN
Middle Name:
Last Name:DEWALT
Suffix:
Gender:F
Credentials:AGNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4729 E BLUE BIRD AVE
Mailing Address - Street 2:
Mailing Address - City:ORANGE
Mailing Address - State:CA
Mailing Address - Zip Code:92869-1918
Mailing Address - Country:US
Mailing Address - Phone:949-293-1456
Mailing Address - Fax:
Practice Address - Street 1:3800 KILROY AIRPORT WAY STE 100
Practice Address - Street 2:
Practice Address - City:LONG BEACH
Practice Address - State:CA
Practice Address - Zip Code:90806-6818
Practice Address - Country:US
Practice Address - Phone:562-527-7600
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-03-30
Last Update Date:2022-01-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA835264163W00000X
CA95006348363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health
No163W00000XNursing Service ProvidersRegistered Nurse