Healthcare Provider Details

I. General information

NPI: 1942251319
Provider Name (Legal Business Name): ANN KATHRYN CARSON PH.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/12/2006
Last Update Date: 10/07/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9261 FULLERTON AVE
SAN DIEGO CA
92123-3146
US

IV. Provider business mailing address

9261 FULLERTON AVE
SAN DIEGO CA
92123-3146
US

V. Phone/Fax

Practice location:
  • Phone: 619-516-0221
  • Fax: 858-496-9782
Mailing address:
  • Phone: 619-516-0221
  • Fax: 858-496-9782

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number1477
License Number StateCA
# 2
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License NumberPSY12884
License Number StateCA
# 3
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License NumberR213694
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: