1194370338 NPI number — MRS. ASHLEE NICOLE-MORTON SOURAPAS LM, CPM

Table of content: MRS. ASHLEE NICOLE-MORTON SOURAPAS LM, CPM (NPI 1194370338)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1194370338 NPI number — MRS. ASHLEE NICOLE-MORTON SOURAPAS LM, CPM

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
SOURAPAS
Provider First Name:
ASHLEE
Provider Middle Name:
NICOLE-MORTON
Provider Name Prefix Text:
MRS.
Provider Name Suffix Text:
Provider Credential Text:
LM, CPM
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
MORTON
Provider Other First Name:
ASHLEE
Provider Other Middle Name:
NICOLE
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1194370338
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
08/05/2019
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
22672 LAMBERT STREET
Provider Second Line Business Mailing Address:
SUITE 611
Provider Business Mailing Address City Name:
LAKE FOREST
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
92630
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
714-261-1458
Provider Business Mailing Address Fax Number:
949-954-8398

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
22672 LAMBERT STREET
Provider Second Line Business Practice Location Address:
SUITE 611
Provider Business Practice Location Address City Name:
LAKE FOREST
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
92630
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
714-261-1458
Provider Business Practice Location Address Fax Number:
949-954-8398
Provider Enumeration Date:
08/05/2019

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 176B00000X , with the licence number:  LM577 , registered in the state of CA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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