Healthcare Provider Details

I. General information

NPI: 1194406470
Provider Name (Legal Business Name): SOPHIA ANNE AGNE RN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/28/2023
Last Update Date: 08/03/2023
Certification Date: 08/03/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3853 ROSECRANS ST
SAN DIEGO CA
92110-3115
US

IV. Provider business mailing address

3853 ROSECRANS ST
SAN DIEGO CA
92110-3115
US

V. Phone/Fax

Practice location:
  • Phone: 619-692-8232
  • Fax: 619-542-4060
Mailing address:
  • Phone: 619-692-8232
  • Fax: 619-692-8232

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163WC1500X
TaxonomyCommunity Health Registered Nurse
License Number566215
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number95314357
License Number StateCA
# 3
Primary TaxonomyY
Taxonomy Code163WP0809X
TaxonomyAdult Psychiatric/Mental Health Registered Nurse
License Number95314357
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: