Provider Demographics
NPI:1295007144
Name:LY, NANCY L (MD)
Entity Type:Individual
Prefix:DR
First Name:NANCY
Middle Name:L
Last Name:LY
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:765 MEDICAL CENTER CT STE 211
Mailing Address - Street 2:
Mailing Address - City:CHULA VISTA
Mailing Address - State:CA
Mailing Address - Zip Code:91911-6600
Mailing Address - Country:US
Mailing Address - Phone:619-616-2100
Mailing Address - Fax:
Practice Address - Street 1:1200 N STATE ST
Practice Address - Street 2:CT-A7D
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90033-1029
Practice Address - Country:US
Practice Address - Phone:323-226-7556
Practice Address - Fax:323-226-2657
Is Sole Proprietor?:No
Enumeration Date:2012-02-07
Last Update Date:2018-01-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
CAA125595207RC0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA113856OtherSID # 113856