1871058727 NPI number — MRS. GINA THERESA LANNEN ATC, CSCS

Table of content: MRS. GINA THERESA LANNEN ATC, CSCS (NPI 1871058727)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1871058727 NPI number — MRS. GINA THERESA LANNEN ATC, CSCS

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
LANNEN
Provider First Name:
GINA
Provider Middle Name:
THERESA
Provider Name Prefix Text:
MRS.
Provider Name Suffix Text:
Provider Credential Text:
ATC, CSCS
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
MAGGIO
Provider Other First Name:
GINA
Provider Other Middle Name:
THERESA
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
ATC, CSCS
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1871058727
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
02/05/2019
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
9073 COVINA ST
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:
92126-3717
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
619-865-3219
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1600 HENDERSON AVE BLDG 573
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:
92140-5000
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
619-524-4101
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
02/05/2019

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: 2255A2300X , with the licence number:  030002048 , registered in the state of CA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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