Provider Demographics
NPI:1407215593
Name:COON, ANASTACIA MARIE (RN, PHN)
Entity Type:Individual
Prefix:
First Name:ANASTACIA
Middle Name:MARIE
Last Name:COON
Suffix:
Gender:F
Credentials:RN, PHN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:865 THIRD AVE STE 121
Mailing Address - Street 2:
Mailing Address - City:CHULA VISTA
Mailing Address - State:CA
Mailing Address - Zip Code:91911-1300
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:865 THIRD AVE STE 121
Practice Address - Street 2:
Practice Address - City:CHULA VISTA
Practice Address - State:CA
Practice Address - Zip Code:91911-1300
Practice Address - Country:US
Practice Address - Phone:619-275-0822
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-02-17
Last Update Date:2017-11-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA95031821163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse