Healthcare Provider Details

I. General information

NPI: 1861564312
Provider Name (Legal Business Name): ANDREW DUNCAN PENN RN, NP, CNS
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/13/2006
Last Update Date: 11/05/2025
Certification Date: 11/05/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4180 LA JOLLA VILLAGE DR STE 240-250
LA JOLLA CA
92037-1402
US

IV. Provider business mailing address

4180 LA JOLLA VILLAGE DR STE 240-250
LA JOLLA CA
92037-1402
US

V. Phone/Fax

Practice location:
  • Phone: 415-793-9240
  • Fax:
Mailing address:
  • Phone: 415-793-9240
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363LA2200X
TaxonomyAdult Health Nurse Practitioner
License Number15914
License Number StateCA
# 2
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number15914
License Number StateCA
# 3
Primary TaxonomyN
Taxonomy Code364SP0808X
TaxonomyPsychiatric/Mental Health Clinical Nurse Specialist
License Number2311
License Number StateCA
# 4
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number621643
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: