Healthcare Provider Details

I. General information

NPI: 1154090405
Provider Name (Legal Business Name): CANDACE KASPERICK
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/09/2021
Last Update Date: 09/09/2021
Certification Date: 09/09/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4350 MOUNT EVEREST BLVD # B12
SAN DIEGO CA
92117-4847
US

IV. Provider business mailing address

PO BOX 7189
SAN DIEGO CA
92167-0189
US

V. Phone/Fax

Practice location:
  • Phone: 858-627-7590
  • Fax:
Mailing address:
  • Phone: 858-395-5852
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WS0200X
TaxonomySchool Registered Nurse
License Number499304
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: