Healthcare Provider Details

I. General information

NPI: 1154749315
Provider Name (Legal Business Name): JOANNA LIZETTE NOLASCO MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/03/2014
Last Update Date: 09/12/2025
Certification Date: 04/26/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

678 THIRD AVE
CHULA VISTA CA
91910-5736
US

IV. Provider business mailing address

1601 PRECISION PARK LN
SAN DIEGO CA
92173-1345
US

V. Phone/Fax

Practice location:
  • Phone: 619-662-4100
  • Fax: 619-662-4100
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberA138919
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: