Healthcare Provider Details

I. General information

NPI: 1689818015
Provider Name (Legal Business Name): THERESA COONEY TIMONY PMHNP-BC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/29/2009
Last Update Date: 08/09/2021
Certification Date: 08/09/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7011 LINDA VISTA RD
SAN DIEGO CA
92111-6307
US

IV. Provider business mailing address

4520 EXECUTIVE DR STE 227
SAN DIEGO CA
92121-3020
US

V. Phone/Fax

Practice location:
  • Phone: 858-810-8787
  • Fax: 858-987-5825
Mailing address:
  • Phone: 858-810-8787
  • Fax: 858-987-5825

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number95007497
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number95039081
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: