Healthcare Provider Details

I. General information

NPI: 1114264363
Provider Name (Legal Business Name): ADELA CAUDILLO FNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/08/2013
Last Update Date: 01/08/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2452 FENTON ST
CHULA VISTA CA
91914-3599
US

IV. Provider business mailing address

3797 CORAL SHORES CT
SAN YSIDRO CA
92173-5912
US

V. Phone/Fax

Practice location:
  • Phone: 619-600-5309
  • Fax:
Mailing address:
  • Phone: 619-690-4677
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number694236
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code163WM0705X
TaxonomyMedical-Surgical Registered Nurse
License Number694236
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: