Healthcare Provider Details

I. General information

NPI: 1558240861
Provider Name (Legal Business Name): MIKALA FANUCCHI RN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/29/2025
Last Update Date: 08/29/2025
Certification Date: 08/29/2025
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

4420 CLEVELAND AVE APT 3
SAN DIEGO CA
92116-3913
US

V. Phone/Fax

Practice location:
  • Phone: 858-637-7888
  • Fax:
Mailing address:
  • Phone: 507-429-2810
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WX0200X
TaxonomyOncology Registered Nurse
License Number95400066
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: