Provider Demographics
NPI:1356951347
Name:DOUGLASS, LINDA (AGACNP-BC)
Entity type:Individual
Prefix:
First Name:LINDA
Middle Name:
Last Name:DOUGLASS
Suffix:
Gender:F
Credentials:AGACNP-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1651 W EL PORTAL DR
Mailing Address - Street 2:
Mailing Address - City:LA HABRA
Mailing Address - State:CA
Mailing Address - Zip Code:90631-4416
Mailing Address - Country:US
Mailing Address - Phone:562-857-2565
Mailing Address - Fax:
Practice Address - Street 1:1651 W EL PORTAL DR
Practice Address - Street 2:
Practice Address - City:LA HABRA
Practice Address - State:CA
Practice Address - Zip Code:90631-4416
Practice Address - Country:US
Practice Address - Phone:562-857-2565
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-08-04
Last Update Date:2020-08-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA95014795363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner