Healthcare Provider Details

I. General information

NPI: 1669611299
Provider Name (Legal Business Name): AUDREY LYNN EATON NURSE PRACTITIONER
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/04/2009
Last Update Date: 12/01/2021
Certification Date: 12/01/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1075 CAMINO DEL RIO S
SAN DIEGO CA
92108-3538
US

IV. Provider business mailing address

34800 BOB WILSON DR
SAN DIEGO CA
92134-5000
US

V. Phone/Fax

Practice location:
  • Phone: 619-881-4500
  • Fax:
Mailing address:
  • Phone: 619-532-6950
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number18489
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number18489
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: