Provider Demographics
NPI:1548905391
Name:LEGACY ADVANCED NURSING PRACTICE INCORPORATED
Entity type:Organization
Organization Name:LEGACY ADVANCED NURSING PRACTICE INCORPORATED
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:NURSE PRACTITIONER
Authorized Official - Prefix:MS
Authorized Official - First Name:TYISHA
Authorized Official - Middle Name:RENEE
Authorized Official - Last Name:FLETCHER
Authorized Official - Suffix:
Authorized Official - Credentials:MSN PMHNP-BC
Authorized Official - Phone:310-251-6727
Mailing Address - Street 1:5318 E 2ND ST # 339
Mailing Address - Street 2:
Mailing Address - City:LONG BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:90803-5324
Mailing Address - Country:US
Mailing Address - Phone:310-251-6727
Mailing Address - Fax:
Practice Address - Street 1:710 N EUCLID ST STE 208
Practice Address - Street 2:
Practice Address - City:ANAHEIM
Practice Address - State:CA
Practice Address - Zip Code:92801-4132
Practice Address - Country:US
Practice Address - Phone:714-844-5804
Practice Address - Fax:714-888-7216
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-05-04
Last Update Date:2022-12-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental HealthGroup - Single Specialty
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamilyGroup - Single Specialty