Healthcare Provider Details

I. General information

NPI: 1558229526
Provider Name (Legal Business Name): PATRICIA ANNA MATUNDAN LACE
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/09/2026
Last Update Date: 01/09/2026
Certification Date: 01/09/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

13941 OLIVE MESA CT
POWAY CA
92064-3952
US

IV. Provider business mailing address

13941 OLIVE MESA CT
POWAY CA
92064-3952
US

V. Phone/Fax

Practice location:
  • Phone: 805-625-4862
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP2300X
TaxonomyPrimary Care Nurse Practitioner
License Number95037609
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: