Provider Demographics
NPI:1295262806
Name:INGERSOLL, SUEANN (PNP, RN, IBCLC)
Entity type:Individual
Prefix:
First Name:SUEANN
Middle Name:
Last Name:INGERSOLL
Suffix:
Gender:F
Credentials:PNP, RN, IBCLC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:26800 CROWN VALLEY PKWY
Mailing Address - Street 2:
Mailing Address - City:MISSION VIEJO
Mailing Address - State:CA
Mailing Address - Zip Code:92691-6384
Mailing Address - Country:US
Mailing Address - Phone:949-362-1380
Mailing Address - Fax:949-347-1510
Practice Address - Street 1:26800 CROWN VALLEY PKWY
Practice Address - Street 2:
Practice Address - City:MISSION VIEJO
Practice Address - State:CA
Practice Address - Zip Code:92691-6384
Practice Address - Country:US
Practice Address - Phone:949-362-1380
Practice Address - Fax:949-347-1510
Is Sole Proprietor?:No
Enumeration Date:2017-05-12
Last Update Date:2017-05-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA16217363LP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPediatrics