MEDICARE: MRS. SUSANA FAVILA FNP

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	363LF0000X	Family Nurse Practitioner	F0414053	CA

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	F0414053	OTHER	CA	NP CERTIFICATION

General Provider Information

NPI Number	:	1447679790
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MRS. SUSANA FAVILA FNP

Provider Business Mailing Address
First Line	:	4225 EXECUTIVE SQ STE 450
Second Line	:
City	:	LA JOLLA
State	:	CA
Zip	:	92037-8411
Country	:	US
Telephone Number	:	858-810-8000
Fax Number	:	858-268-1911

Provider Business Practice Location Address
First Line	:	2205 ROSS AVE STE 101
Second Line	:
City	:	EL CENTRO
State	:	CA
Zip	:	92243-3623
Country	:	US
Telephone Number	:	760-353-0404
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	04/15/2014
Last Update Date	:	02/10/2021

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