Healthcare Provider Details

I. General information

NPI: 1124586813
Provider Name (Legal Business Name): ANDREA KAMILLE CONANAN MS
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/12/2019
Last Update Date: 06/27/2024
Certification Date: 06/27/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3130 5TH AVE # 3
SAN DIEGO CA
92103-5839
US

IV. Provider business mailing address

2307 FENTON PKWY STE 107-257
SAN DIEGO CA
92108-4746
US

V. Phone/Fax

Practice location:
  • Phone: 858-707-5301
  • Fax:
Mailing address:
  • Phone: 858-707-5301
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number13059
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number5241
License Number StateCA
# 3
Primary TaxonomyN
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number13059
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: