Provider Demographics
NPI:1780138198
Name:WALDBAUM, MICHELLE LEA (BSN, RN, CNOR, RNFA)
Entity type:Individual
Prefix:MRS
First Name:MICHELLE
Middle Name:LEA
Last Name:WALDBAUM
Suffix:
Gender:F
Credentials:BSN, RN, CNOR, RNFA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5902 NUGGET CIR
Mailing Address - Street 2:
Mailing Address - City:HUNTINGTON BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:92647-2131
Mailing Address - Country:US
Mailing Address - Phone:714-951-1469
Mailing Address - Fax:
Practice Address - Street 1:5902 NUGGET CIR
Practice Address - Street 2:
Practice Address - City:HUNTINGTON BEACH
Practice Address - State:CA
Practice Address - Zip Code:92647-2131
Practice Address - Country:US
Practice Address - Phone:714-951-1469
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-08-15
Last Update Date:2020-09-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA95022225163W00000X, 163WR0006X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WR0006XNursing Service ProvidersRegistered NurseRegistered Nurse First Assistant
No163W00000XNursing Service ProvidersRegistered Nurse