Healthcare Provider Details

I. General information

NPI: 1063800316
Provider Name (Legal Business Name): ANA KUKULJ
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/08/2015
Last Update Date: 01/08/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5167 SEA MIST CT
SAN DIEGO CA
92121-4228
US

IV. Provider business mailing address

5167 SEA MIST CT
SAN DIEGO CA
92121-4228
US

V. Phone/Fax

Practice location:
  • Phone: 619-889-0603
  • Fax:
Mailing address:
  • Phone: 619-889-0603
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number95001490
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: