Provider Demographics
NPI:1245467992
Name:DAVID, MARY LOU LAO (FNP-BC)
Entity type:Individual
Prefix:
First Name:MARY LOU
Middle Name:LAO
Last Name:DAVID
Suffix:
Gender:F
Credentials:FNP-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4050 BARRANCA PKWY
Mailing Address - Street 2:
Mailing Address - City:IRVINE
Mailing Address - State:CA
Mailing Address - Zip Code:92604-7706
Mailing Address - Country:US
Mailing Address - Phone:949-551-1090
Mailing Address - Fax:949-262-5500
Practice Address - Street 1:22 BLUFF COVE DR
Practice Address - Street 2:
Practice Address - City:ALISO VIEJO
Practice Address - State:CA
Practice Address - Zip Code:92656-8077
Practice Address - Country:US
Practice Address - Phone:949-360-0587
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-06-19
Last Update Date:2017-10-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA18743363LP2300X, 363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP2300XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPrimary Care
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily