Provider Demographics
NPI:1164953576
Name:HODGE, DAISIANETTE (RN)
Entity Type:Individual
Prefix:MRS
First Name:DAISIANETTE
Middle Name:
Last Name:HODGE
Suffix:
Gender:F
Credentials:RN
Other - Prefix:
Other - First Name:DAISY
Other - Middle Name:
Other - Last Name:HODGE
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:8510 LARKDALE AVE
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92123-2050
Mailing Address - Country:US
Mailing Address - Phone:601-212-5022
Mailing Address - Fax:
Practice Address - Street 1:1250 MORENA BLVD
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92110-3815
Practice Address - Country:US
Practice Address - Phone:619-692-8750
Practice Address - Fax:619-692-8779
Is Sole Proprietor?:No
Enumeration Date:2017-03-27
Last Update Date:2018-09-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA686560164X00000X
CA95169891163WP0809X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WP0809XNursing Service ProvidersRegistered NursePsychiatric/Mental Health, Adult
No164X00000XNursing Service ProvidersLicensed Vocational Nurse