Healthcare Provider Details

I. General information

NPI: 1023632684
Provider Name (Legal Business Name): MINOLI GUNETILEKE RN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/29/2020
Last Update Date: 05/29/2020
Certification Date: 05/29/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6991 BALBOA AVE RM 70
SAN DIEGO CA
92111-3447
US

IV. Provider business mailing address

6991 BALBOA AVE RM 70
SAN DIEGO CA
92111-3447
US

V. Phone/Fax

Practice location:
  • Phone: 858-496-8232
  • Fax: 858-496-8234
Mailing address:
  • Phone: 858-496-8232
  • Fax: 858-496-8234

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number95220016
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: