Basic Information
| Provider Information | |||||||||
| NPI: | 1538790340 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | LAU | ||||||||
| FirstName: | ANNETTE | ||||||||
| MiddleName: | DORIA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 623 N VOGUE AVE | ||||||||
| Address2: | |||||||||
| City: | COVINA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 917223527 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6268589938 | ||||||||
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| Practice Location | |||||||||
| Address1: | 210 W SAN BERNARDINO RD | ||||||||
| Address2: | |||||||||
| City: | COVINA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 917231515 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6269387650 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 01/30/2020 | ||||||||
| LastUpdateDate: | 01/30/2020 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 01/30/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 163WP0809X | 453883 | CA | Y | Nursing Service Providers | Registered Nurse | Psych/Mental Health, Adult |
No ID Information.