=====================================================
General NPI Number Information
=====================================================
NPI Number | 1790070159
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | JULIE ANNE LANGE M.D.
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/14/2011
-----------------------------------------------------
Last Update Date | 12/06/2021
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 4660 PALM AVE BLDG 4, 2ND FLOOR
-----------------------------------------------------
City | SAN DIEGO
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 92154-8404
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 619-952-7804
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 4660 PALM AVE BLDG 4, 2ND FLOOR
-----------------------------------------------------
City | SAN DIEGO
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 92154-8404
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 877-496-0450
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 2084P0800X
-----------------------------------------------------
Taxonomy Name | Psychiatry Physician
-----------------------------------------------------
License Number | A123253
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------