Healthcare Provider Details

I. General information

NPI: 1093619173
Provider Name (Legal Business Name): VANESSA DAWN COMOLA MSTOM
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/05/2026
Last Update Date: 10/05/2026
Certification Date: 10/04/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12759 POWAY RD STE 10
POWAY CA
92064-4438
US

IV. Provider business mailing address

12759 POWAY RD STE 10
POWAY CA
92064-4438
US

V. Phone/Fax

Practice location:
  • Phone: 858-748-9880
  • Fax:
Mailing address:
  • Phone: 858-748-9880
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code171100000X
TaxonomyAcupuncturist
License Number8936
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: