Healthcare Provider Details

I. General information

NPI: 1982181277
Provider Name (Legal Business Name): HANNAH MULDOON BERRY
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/19/2018
Last Update Date: 07/19/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3511 CAMINO DEL RIO S
SAN DIEGO CA
92108-4003
US

IV. Provider business mailing address

6372 STANLEY AVE
SAN DIEGO CA
92115-4146
US

V. Phone/Fax

Practice location:
  • Phone: 619-436-4263
  • Fax:
Mailing address:
  • Phone: 619-756-2856
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code247200000X
TaxonomyOther Technician
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: