Healthcare Provider Details

I. General information

NPI: 1669944369
Provider Name (Legal Business Name): KATHLEEN MARIE MACKESSY FNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/19/2018
Last Update Date: 11/06/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6155 CORNERSTONE CT E STE 220
SAN DIEGO CA
92121-4737
US

IV. Provider business mailing address

1021 MUSEUM CT
OCEANSIDE CA
92057-7904
US

V. Phone/Fax

Practice location:
  • Phone: 858-458-2993
  • Fax:
Mailing address:
  • Phone: 760-672-9476
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208M00000X
TaxonomyHospitalist Physician
License NumberNPF95010414
License Number StateCA
# 2
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberNPF95010414
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: