Healthcare Provider Details

I. General information

NPI: 1033631700
Provider Name (Legal Business Name): CHELSEA PROVENZANO MSN, FNP- C
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/13/2017
Last Update Date: 07/13/2017
Certification Date:
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

13627 SUNSET VIEW RD
POWAY CA
92064-5051
US

V. Phone/Fax

Practice location:
  • Phone: 619-583-1174
  • Fax: 619-583-4609
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number95006939
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: