1215270889 NPI number — MS. KANDACE MICHAELE ELLIS-BURNETT BA

Table of content: MS. KANDACE MICHAELE ELLIS-BURNETT BA (NPI 1215270889)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1215270889 NPI number — MS. KANDACE MICHAELE ELLIS-BURNETT BA

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
ELLIS-BURNETT
Provider First Name:
KANDACE
Provider Middle Name:
MICHAELE
Provider Name Prefix Text:
MS.
Provider Name Suffix Text:
Provider Credential Text:
BA
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
ELLIS
Provider Other First Name:
KANDACE
Provider Other Middle Name:
MICHAELE
Provider Other Name Prefix Text:
MISS
Provider Other Name Suffix Text:
Provider Other Credential Text:
BA
Provider Other Last Name Type Code:
2

NPI Number Information

NPI Number:
1215270889
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
05/05/2022
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
8910 CLAIREMONT MESA BLVD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
SAN DIEGO
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
92123-1104
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
858-514-5100
Provider Business Mailing Address Fax Number:
858-514-5190

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
3148 MIDWAY DR STE 113
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
SAN DIEGO
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
92110-4539
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
619-363-0853
Provider Business Practice Location Address Fax Number:
619-362-9905
Provider Enumeration Date:
04/02/2013

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 175T00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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