Healthcare Provider Details

I. General information

NPI: 1780024588
Provider Name (Legal Business Name): FAZELA WASIMI NP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/26/2013
Last Update Date: 03/22/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4692 MISSION BLVD
SAN DIEGO CA
92109-2734
US

IV. Provider business mailing address

7946 LAKE ADLON DR
SAN DIEGO CA
92119-3117
US

V. Phone/Fax

Practice location:
  • Phone: 619-647-5072
  • Fax: 619-330-4782
Mailing address:
  • Phone: 619-303-0497
  • Fax: 619-330-4782

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code364SF0001X
TaxonomyFamily Health Clinical Nurse Specialist
License Number22375
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number696952
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: