Provider Demographics
NPI:1104170323
Name:VILLASENOR, LAURA KAY (FNP-BC)
Entity type:Individual
Prefix:
First Name:LAURA
Middle Name:KAY
Last Name:VILLASENOR
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 1:115 SPANISH LACE
Mailing Address - Street 2:
Mailing Address - City:IRVINE
Mailing Address - State:CA
Mailing Address - Zip Code:92620-3424
Mailing Address - Country:US
Mailing Address - Phone:651-335-6497
Mailing Address - Fax:
Practice Address - Street 1:4980 BARRANCA PKWY
Practice Address - Street 2:SUITE 200
Practice Address - City:IRVINE
Practice Address - State:CA
Practice Address - Zip Code:92604-8645
Practice Address - Country:US
Practice Address - Phone:949-786-5050
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-11-09
Last Update Date:2012-11-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA22221363LP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP2300XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPrimary Care