Healthcare Provider Details

I. General information

NPI: 1639636004
Provider Name (Legal Business Name): DENNAFAYE DAGHLIAN PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: DENNAFAYE HERALD PA

II. Dates (important events)

Enumeration Date: 02/21/2019
Last Update Date: 03/29/2022
Certification Date: 03/29/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

15004 INNOVATION DR
SAN DIEGO CA
92128-3498
US

IV. Provider business mailing address

10790 RANCHO BERNARDO RD # 4S-205
SAN DIEGO CA
92127-5705
US

V. Phone/Fax

Practice location:
  • Phone: 858-605-7837
  • Fax:
Mailing address:
  • Phone: 858-605-7171
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number56534
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: