MEDICARE: SAMANTHA ROSE FEZZEY RN, BSN

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	163W00000X	Registered Nurse	95224868	CA

General Provider Information

NPI Number	:	1710590351
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	SAMANTHA ROSE FEZZEY RN, BSN

Provider Business Mailing Address
First Line	:	16345 OAKLEY RD
Second Line	:
City	:	RAMONA
State	:	CA
Zip	:	92065-4270
Country	:	US
Telephone Number	:	760-315-7196
Fax Number	:

Provider Business Practice Location Address
First Line	:	5530 OVERLAND AVE STE 210
Second Line	:
City	:	SAN DIEGO
State	:	CA
Zip	:	92123-1261
Country	:	US
Telephone Number	:	619-236-2191
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	08/24/2020
Last Update Date	:	08/24/2020

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