Healthcare Provider Details

I. General information

NPI: 1023809134
Provider Name (Legal Business Name): TEAGAN SHEA COLEMAN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/16/2025
Last Update Date: 05/16/2025
Certification Date: 05/16/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5555 GROSSMONT CENTER DR
LA MESA CA
91942-3019
US

IV. Provider business mailing address

3676 ALTA VISTA DR
FALLBROOK CA
92028-9112
US

V. Phone/Fax

Practice location:
  • Phone: 619-740-6000
  • Fax:
Mailing address:
  • Phone: 707-494-7134
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WE0003X
TaxonomyEmergency Registered Nurse
License Number95365022
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: