Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 363LW0102X | Nurse Practitioner - Women's Health | 22352 | CA |
NPI | 1083958870 |
---|---|
Provider Name | Courtney Proctor |
First Address | Costa Mesa, CA 92627 |
Second Address | Costa Mesa, CA 92627-5060 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 16/11/2012 |
Last Update Date | 16/11/2012 |