Healthcare Provider Details

I. General information

NPI: 1538693239
Provider Name (Legal Business Name): ANDREA LYNN PROCKO MS, PHD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: ANDREA LYNN GEOGHEGAN

II. Dates (important events)

Enumeration Date: 04/19/2017
Last Update Date: 05/01/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4910 DIRECTORS PL
SAN DIEGO CA
92121-3811
US

IV. Provider business mailing address

9300 CAMPUS POINT DR MAIL CODE #7768
LA JOLLA CA
92037-1300
US

V. Phone/Fax

Practice location:
  • Phone: 858-657-7200
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code170300000X
TaxonomyGenetic Counselor (M.S.)
License NumberGC000797
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: