=====================================================
General NPI Number Information
=====================================================
NPI Number | 1972929404
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | KATHERINE ROSE LAIS DNP, PMHNP-BC
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/07/2014
-----------------------------------------------------
Last Update Date | 09/21/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 855 E MADISON AVE
-----------------------------------------------------
City | EL CAJON
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 92020-3819
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 619-440-2751
-----------------------------------------------------
Fax | 619-440-2945
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 3050 RUE DORLEANS UNIT 382
-----------------------------------------------------
City | SAN DIEGO
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 92110-5927
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 512-571-0440
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 363LP0808X
-----------------------------------------------------
Taxonomy Name | Psychiatric/Mental Health Nurse Practitioner
-----------------------------------------------------
License Number | 95002763
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 163W00000X
-----------------------------------------------------
Taxonomy Name | Registered Nurse
-----------------------------------------------------
License Number | 840984
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------