Healthcare Provider Details

I. General information

NPI: 1730740036
Provider Name (Legal Business Name): ADRIANA YVETTE SOUTHWORTH DNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: ADRIANA YVETTE FONTES

II. Dates (important events)

Enumeration Date: 06/26/2019
Last Update Date: 06/27/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9898 GENESEE AVE
LA JOLLA CA
92037-1205
US

IV. Provider business mailing address

10790 RANCHO BERNARDO RD # 4S-205
SAN DIEGO CA
92127-5705
US

V. Phone/Fax

Practice location:
  • Phone: 858-824-5424
  • Fax:
Mailing address:
  • Phone: 858-824-5424
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number460449
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: