Healthcare Provider Details

I. General information

NPI: 1144606963
Provider Name (Legal Business Name): MICHAEL SCOTT FITZGERALD PMHNP
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/04/2015
Last Update Date: 07/25/2025
Certification Date: 07/25/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1111 6TH AVE STE 550
SAN DIEGO CA
92101-5211
US

IV. Provider business mailing address

17271 GRANDEE PL
SAN DIEGO CA
92128-2364
US

V. Phone/Fax

Practice location:
  • Phone: 510-283-8560
  • Fax:
Mailing address:
  • Phone: 510-283-8560
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number9502706
License Number StateCA
# 2
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number95022706
License Number StateCA
# 3
Primary TaxonomyN
Taxonomy Code163WP0808X
TaxonomyPsychiatric/Mental Health Registered Nurse
License Number95026924
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: