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General NPI Number Information
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NPI Number | 1558240861
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Entity Type | Individual
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Provider Name | MIKALA FANUCCHI RN
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Gender | Female
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Dates
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Enumeration Date | 08/29/2025
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Last Update Date | 08/29/2025
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Provider Practice Location Address
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Address Line | 3075 HEALTH CENTER DR STE 102
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City | SAN DIEGO
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State | CA
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Zip | 92123-2773
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Country | US
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Telephone | 858-637-7888
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Fax |
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Provider Business Mailing Address
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Address Line | 4420 CLEVELAND AVE APT 3
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City | SAN DIEGO
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State | CA
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Zip | 92116-3913
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Country | US
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Telephone | 507-429-2810
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 163WX0200X
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Taxonomy Name | Oncology Registered Nurse
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License Number | 95400066
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License Number State | CA
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