Healthcare Provider Details

I. General information

NPI: 1780825679
Provider Name (Legal Business Name): GEORGINA MAXINE MICHAEL NP
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/23/2009
Last Update Date: 06/28/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

200 WEST ARBOR DRIVE #8896
SAN DIEGO CA
92103-8896
US

IV. Provider business mailing address

3254 HOLLY WAY
CHULA VISTA CA
91910
US

V. Phone/Fax

Practice location:
  • Phone: 619-543-7276
  • Fax: 619-543-6004
Mailing address:
  • Phone: 619-739-0955
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163WC0200X
TaxonomyCritical Care Medicine Registered Nurse
License Number565983
License Number StateCA
# 2
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number13763
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: