Healthcare Provider Details

I. General information

NPI: 1801920863
Provider Name (Legal Business Name): DIANE SUE BEWLEY BSN, RN, PHN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/14/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3851 ROSECRANS ST
SAN DIEGO CA
92110-3115
US

IV. Provider business mailing address

3013 LUNA AVE
SAN DIEGO CA
92117-2515
US

V. Phone/Fax

Practice location:
  • Phone: 619-692-5742
  • Fax: 619-692-5650
Mailing address:
  • Phone: 858-270-5068
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number369400
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: