Healthcare Provider Details

I. General information

NPI: 1639945132
Provider Name (Legal Business Name): DIONDRENIK HARRISON
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/27/2023
Last Update Date: 05/27/2026
Certification Date: 05/27/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3002 ARMSTRONG ST
SAN DIEGO CA
92111-5702
US

IV. Provider business mailing address

3002 ARMSTRONG ST
SAN DIEGO CA
92111-5702
US

V. Phone/Fax

Practice location:
  • Phone: 858-633-4100
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code373H00000X
TaxonomyDay Training/Habilitation Specialist
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code172V00000X
TaxonomyCommunity Health Worker
License Number
License Number StateNULL
# 3
Primary TaxonomyY
Taxonomy Code175T00000X
TaxonomyPeer Specialist
License NumberMPSS-DYJKEP
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: