Healthcare Provider Details

I. General information

NPI: 1316768898
Provider Name (Legal Business Name): COLE PELLEGRINO FNP-C
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/18/2024
Last Update Date: 10/18/2024
Certification Date: 10/11/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

142 ENCINITAS BLVD
ENCINITAS CA
92024-3657
US

IV. Provider business mailing address

6732 ANTILOPE ST
CARLSBAD CA
92009-5805
US

V. Phone/Fax

Practice location:
  • Phone: 760-230-1880
  • Fax:
Mailing address:
  • Phone: 609-471-3951
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number95032629
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: