Healthcare Provider Details

I. General information

NPI: 1841311800
Provider Name (Legal Business Name): GWENMARIE ANGELIQUE HILLEARY MHA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/03/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9065 EDGEMOOR DR
SANTEE CA
92071-3037
US

IV. Provider business mailing address

12286 CREEKSIDE CT
SAN DIEGO CA
92131-1552
US

V. Phone/Fax

Practice location:
  • Phone: 619-956-2800
  • Fax: 619-956-2897
Mailing address:
  • Phone: 619-956-2800
  • Fax: 619-956-2897

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: