Provider Demographics
NPI:1467753129
Name:GHADERIFARD, AZITA (FNP)
Entity Type:Individual
Prefix:MS
First Name:AZITA
Middle Name:
Last Name:GHADERIFARD
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:23101 LAKE CENTER DR
Mailing Address - Street 2:130
Mailing Address - City:LAKE FOREST
Mailing Address - State:CA
Mailing Address - Zip Code:92630-2801
Mailing Address - Country:US
Mailing Address - Phone:949-716-9021
Mailing Address - Fax:949-861-6810
Practice Address - Street 1:23101 LAKE CENTER DR
Practice Address - Street 2:130
Practice Address - City:LAKE FOREST
Practice Address - State:CA
Practice Address - Zip Code:92630-2801
Practice Address - Country:US
Practice Address - Phone:949-716-9021
Practice Address - Fax:949-861-6810
Is Sole Proprietor?:Yes
Enumeration Date:2010-11-11
Last Update Date:2013-11-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA14410363LF0000X
TX577516363LA2200X, 363LF0000X, 363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner