Basic Information
| Provider Information | |||||||||
| NPI: | 1326653056 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | SHORE | ||||||||
| FirstName: | DECEMBER | ||||||||
| MiddleName: | LORAINE | ||||||||
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| Credential: | RN | ||||||||
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| Mailing Information | |||||||||
| Address1: | 5800 SOUTH ST APT 173 | ||||||||
| Address2: | |||||||||
| City: | LAKEWOOD | ||||||||
| State: | CA | ||||||||
| PostalCode: | 907131332 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5623401314 | ||||||||
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| Practice Location | |||||||||
| Address1: | 301 VICTORIA ST | ||||||||
| Address2: | |||||||||
| City: | COSTA MESA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 926277131 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9496422734 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/10/2020 | ||||||||
| LastUpdateDate: | 09/10/2020 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 09/09/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 163WP0808X | 95177107 | CA | Y | Nursing Service Providers | Registered Nurse | Psych/Mental Health |
No ID Information.