Healthcare Provider Details

I. General information

NPI: 1003065897
Provider Name (Legal Business Name): JENNIFER LEE HANLEY PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: JENNIFER LEE SCHMOLLINGER AND KISSEE PA-C

II. Dates (important events)

Enumeration Date: 09/16/2008
Last Update Date: 11/30/2021
Certification Date: 11/30/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6655 ALVARADO RD
SAN DIEGO CA
92120-5208
US

IV. Provider business mailing address

6450 TOPMAST DR
CARLSBAD CA
92011-1252
US

V. Phone/Fax

Practice location:
  • Phone: 949-632-5442
  • Fax:
Mailing address:
  • Phone: 949-632-5442
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License NumberPA19927
License Number StateCA
# 2
Primary TaxonomyY
Taxonomy Code363AS0400X
TaxonomySurgical Physician Assistant
License Number19927
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: