Healthcare Provider Details

I. General information

NPI: 1255012860
Provider Name (Legal Business Name): CORAL ROSEBERRY DNP, FNP, AGNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/26/2023
Last Update Date: 08/23/2023
Certification Date: 08/23/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8851 CENTER DR STE 408
LA MESA CA
91942-3076
US

IV. Provider business mailing address

9395 HARRITT RD SPC 111
LAKESIDE CA
92040-3530
US

V. Phone/Fax

Practice location:
  • Phone: 619-583-1174
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License NumberRN95169759
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code363LG0600X
TaxonomyGerontology Nurse Practitioner
License Number95026375
License Number StateCA
# 3
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number95026375
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: