Provider Demographics
NPI:1194229757
Name:TELLO, MICHELLE GANANGAN
Entity Type:Individual
Prefix:
First Name:MICHELLE
Middle Name:GANANGAN
Last Name:TELLO
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10108 CALLE MARINERO APT 66
Mailing Address - Street 2:
Mailing Address - City:SPRING VALLEY
Mailing Address - State:CA
Mailing Address - Zip Code:91977-7114
Mailing Address - Country:US
Mailing Address - Phone:619-315-6575
Mailing Address - Fax:
Practice Address - Street 1:655 PARK CENTER DR
Practice Address - Street 2:
Practice Address - City:SANTEE
Practice Address - State:CA
Practice Address - Zip Code:92071-6957
Practice Address - Country:US
Practice Address - Phone:619-596-5500
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-03-20
Last Update Date:2018-03-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA629830163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse