Healthcare Provider Details

I. General information

NPI: 1508461328
Provider Name (Legal Business Name): ANNALYCIA VICTORIA HUTT
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/01/2020
Last Update Date: 03/28/2024
Certification Date: 03/28/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3517 CAMINO DEL RIO S
SAN DIEGO CA
92108-4026
US

IV. Provider business mailing address

1536 MOORLAND DR
SAN DIEGO CA
92109-6675
US

V. Phone/Fax

Practice location:
  • Phone: 619-955-8905
  • Fax:
Mailing address:
  • Phone: 916-897-3289
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code172V00000X
TaxonomyCommunity Health Worker
License Number
License Number StateNULL
# 2
Primary TaxonomyY
Taxonomy Code175T00000X
TaxonomyPeer Specialist
License NumberMPSS-BGEYNR
License Number StateCA
# 3
Primary TaxonomyN
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: