Healthcare Provider Details

I. General information

NPI: 1083982987
Provider Name (Legal Business Name): KORNELIA ANNA KOPEC DNP
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/06/2011
Last Update Date: 06/14/2022
Certification Date: 06/14/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3075 HEALTH CENTER DR STE 102
SAN DIEGO CA
92123-2773
US

IV. Provider business mailing address

3075 HEALTH CENTER DR STE 102
SAN DIEGO CA
92123-2773
US

V. Phone/Fax

Practice location:
  • Phone: 858-637-7888
  • Fax: 858-637-7887
Mailing address:
  • Phone: 858-637-7888
  • Fax: 858-362-4027

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163WC1600X
TaxonomyContinuing Education/Staff Development Registered Nurse
License Number672382
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License NumberNPF95004764
License Number StateCA
# 3
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number95004764
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: