Healthcare Provider Details

I. General information

NPI: 1215362561
Provider Name (Legal Business Name): MEGAN KELLIE SUWARA FNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: MEGAN KELLIE MCCULLOCH FNP-BC

II. Dates (important events)

Enumeration Date: 09/05/2013
Last Update Date: 08/18/2023
Certification Date: 08/18/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

49617 CESAR CHAVEZ ST STE B
COACHELLA CA
92236-1535
US

IV. Provider business mailing address

45300 PORTOLA AVE UNIT 2192
PALM DESERT CA
92261-7089
US

V. Phone/Fax

Practice location:
  • Phone: 760-398-3555
  • Fax:
Mailing address:
  • Phone: 760-398-3555
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number23608
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: