Provider Demographics
NPI:1295231371
Name:HVIZDZAK, KAREN ANN (NP)
Entity Type:Individual
Prefix:MRS
First Name:KAREN
Middle Name:ANN
Last Name:HVIZDZAK
Suffix:
Gender:F
Credentials:NP
Other - Prefix:MS
Other - First Name:KAREN
Other - Middle Name:ANN
Other - Last Name:MACKALL
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:NP
Mailing Address - Street 1:8775 AERO DR
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92123-1792
Mailing Address - Country:US
Mailing Address - Phone:619-400-5050
Mailing Address - Fax:619-400-5055
Practice Address - Street 1:8875 AERO DR
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92123-2251
Practice Address - Country:US
Practice Address - Phone:619-400-5050
Practice Address - Fax:619-400-5055
Is Sole Proprietor?:Yes
Enumeration Date:2018-04-05
Last Update Date:2023-09-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
171000000X
CA95009159363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamilyGroup - Multi-Specialty
No171000000XOther Service ProvidersMilitary Health Care ProviderGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA363LF0000XMedicaid