MEDICARE: MISS MARISSA ELIZABETH KIENTZ REGISTERED NURSE

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	163WM0102X	Maternal Newborn Registered Nurse	718949	CA

General Provider Information

NPI Number	:	1912597501
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MISS MARISSA ELIZABETH KIENTZ REGISTERED NURSE

Provider Business Mailing Address
First Line	:	2515 RAMFOS PL
Second Line	:
City	:	SAN DIEGO
State	:	CA
Zip	:	92139-2822
Country	:	US
Telephone Number	:	619-863-3540
Fax Number	:

Provider Business Practice Location Address
First Line	:	2515 RAMFOS PL
Second Line	:
City	:	SAN DIEGO
State	:	CA
Zip	:	92139-2822
Country	:	US
Telephone Number	:	619-863-3540
Fax Number	:

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

Provider Enumeration Date	:	01/19/2021
Last Update Date	:	01/19/2021

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