Basic Information
| Provider Information | |||||||||
| NPI: | 1730370172 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MORDUE-LAIN | ||||||||
| FirstName: | DENISE | ||||||||
| MiddleName: | AUDREY | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | NP | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | MORGAN | ||||||||
| OtherFirstName: | DENISE | ||||||||
| OtherMiddleName: | AUDREY | ||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | NP | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 1919 VISTA DEL LAGO DR | ||||||||
| Address2: | |||||||||
| City: | VALLEY SPRINGS | ||||||||
| State: | CA | ||||||||
| PostalCode: | 952529294 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2097729538 | ||||||||
| FaxNumber: | 2097720312 | ||||||||
| Practice Location | |||||||||
| Address1: | 1919 VISTA DEL LAGO DR | ||||||||
| Address2: | |||||||||
| City: | VALLEY SPRINGS | ||||||||
| State: | CA | ||||||||
| PostalCode: | 952529294 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2097729538 | ||||||||
| FaxNumber: | 2097720312 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/08/2007 | ||||||||
| LastUpdateDate: | 04/19/2017 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
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| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 163WW0101X | NP6294 | CA | Y | Nursing Service Providers | Registered Nurse | Women's Health Care, Ambulatory |
No ID Information.