Provider Demographics
NPI:1053025239
Name:BANDOLIN, LAURENE (NP)
Entity type:Individual
Prefix:MS
First Name:LAURENE
Middle Name:
Last Name:BANDOLIN
Suffix:
Gender:F
Credentials:NP
Other - Prefix:MRS
Other - First Name:LAURENE
Other - Middle Name:
Other - Last Name:SANDOVAL
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:22885 HILTON HEAD DR UNIT 263
Mailing Address - Street 2:
Mailing Address - City:DIAMOND BAR
Mailing Address - State:CA
Mailing Address - Zip Code:91765-4415
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1100 W TOWN AND COUNTRY RD STE 1300
Practice Address - Street 2:
Practice Address - City:ORANGE
Practice Address - State:CA
Practice Address - Zip Code:92868-4654
Practice Address - Country:US
Practice Address - Phone:855-434-7763
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-01-11
Last Update Date:2023-01-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA95036098163W00000X
CA95022508363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No163W00000XNursing Service ProvidersRegistered Nurse