Provider Demographics
NPI:1750827465
Name:PENUEL, LAURA MARIE
Entity type:Individual
Prefix:
First Name:LAURA
Middle Name:MARIE
Last Name:PENUEL
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2575 YORBA LINDA BLVD
Mailing Address - Street 2:
Mailing Address - City:FULLERTON
Mailing Address - State:CA
Mailing Address - Zip Code:92831-1615
Mailing Address - Country:US
Mailing Address - Phone:951-233-6560
Mailing Address - Fax:
Practice Address - Street 1:2575 YORBA LINDA BLVD
Practice Address - Street 2:
Practice Address - City:FULLERTON
Practice Address - State:CA
Practice Address - Zip Code:92831-1615
Practice Address - Country:US
Practice Address - Phone:951-233-6560
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-01-19
Last Update Date:2024-06-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX247200000X
363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
No247200000XTechnologists, Technicians & Other Technical Service ProvidersTechnician, Other