Healthcare Provider Details

I. General information

NPI: 1619788759
Provider Name (Legal Business Name): MAGGIE MCENERNEY PMHNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/17/2025
Last Update Date: 08/08/2026
Certification Date: 08/08/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

427 9TH AVE UNIT 1009
SAN DIEGO CA
92101-7371
US

IV. Provider business mailing address

427 9TH AVE UNIT 1009
SAN DIEGO CA
92101-7371
US

V. Phone/Fax

Practice location:
  • Phone: 224-489-9071
  • Fax:
Mailing address:
  • Phone: 224-489-9071
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number10063070
License Number StateOR
# 2
Primary TaxonomyN
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number342915
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: