Healthcare Provider Details

I. General information

NPI: 1245979814
Provider Name (Legal Business Name): NIROSHA GNANASSEGARANE
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/02/2022
Last Update Date: 06/21/2022
Certification Date: 06/21/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

477 N EL CAMINO REAL STE B303
ENCINITAS CA
92024-1331
US

IV. Provider business mailing address

10790 RANCHO BERNARDO RD
SAN DIEGO CA
92127-5705
US

V. Phone/Fax

Practice location:
  • Phone: 760-479-3900
  • Fax:
Mailing address:
  • Phone: 760-479-3900
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number95020981
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: