Healthcare Provider Details

I. General information

NPI: 1770359812
Provider Name (Legal Business Name): ELIZABETH PATTY CPNP-AC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/29/2023
Last Update Date: 11/29/2023
Certification Date: 11/29/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3020 CHILDRENS WAY
SAN DIEGO CA
92123-4223
US

IV. Provider business mailing address

2083 TREVI CIR
CHULA VISTA CA
91913-3770
US

V. Phone/Fax

Practice location:
  • Phone: 858-966-5855
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP0200X
TaxonomyPediatric Nurse Practitioner
License Number95028117
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: