Healthcare Provider Details

I. General information

NPI: 1790341253
Provider Name (Legal Business Name): MADISON WEISS RN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/10/2019
Last Update Date: 05/10/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3250 COUNTRY ROSE CIR
ENCINITAS CA
92024-5708
US

IV. Provider business mailing address

1166 PARK BLVD APT 211
SAN DIEGO CA
92101-5620
US

V. Phone/Fax

Practice location:
  • Phone: 619-639-7325
  • Fax:
Mailing address:
  • Phone: 619-919-9919
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WA0400X
TaxonomyAddiction (Substance Use Disorder) Registered Nurse
License Number95144643
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: