MEDICARE: KATHLEEN MARIE MACKESSY 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	208M00000X	Hospitalist Physician	NPF95010414	CA
2	363LF0000X	Family Nurse Practitioner	NPF95010414	CA

General Provider Information

NPI Number	:	1669944369
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	KATHLEEN MARIE MACKESSY FNP

Provider Business Mailing Address
First Line	:	1021 MUSEUM CT
Second Line	:
City	:	OCEANSIDE
State	:	CA
Zip	:	92057-7904
Country	:	US
Telephone Number	:	760-672-9476
Fax Number	:

Provider Business Practice Location Address
First Line	:	6155 CORNERSTONE CT E STE 220
Second Line	:
City	:	SAN DIEGO
State	:	CA
Zip	:	92121-4737
Country	:	US
Telephone Number	:	858-458-2993
Fax Number	:

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

Provider Enumeration Date	:	12/19/2018
Last Update Date	:	11/06/2019

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