Healthcare Provider Details

I. General information

NPI: 1841932316
Provider Name (Legal Business Name): DARLA RUTH MUDGE LAATSCH FNP
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/13/2022
Last Update Date: 06/09/2022
Certification Date: 05/25/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3073 COLINA VERDE LN
JAMUL CA
91935-3005
US

IV. Provider business mailing address

3073 COLINA VERDE LN
JAMUL CA
91935-3005
US

V. Phone/Fax

Practice location:
  • Phone: 619-507-0848
  • Fax:
Mailing address:
  • Phone: 619-303-2671
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number407472
License Number StateCA
# 2
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number95021056
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: