Provider Demographics
NPI:1417688722
Name:FITZGERALD, MICHAEL CHARLES (RN,CNS)
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:CHARLES
Last Name:FITZGERALD
Suffix:
Gender:M
Credentials:RN,CNS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:203 BRACKNEY RD
Mailing Address - Street 2:
Mailing Address - City:BEN LOMOND
Mailing Address - State:CA
Mailing Address - Zip Code:95005-9702
Mailing Address - Country:US
Mailing Address - Phone:831-818-1934
Mailing Address - Fax:
Practice Address - Street 1:203 BRACKNEY RD
Practice Address - Street 2:
Practice Address - City:BEN LOMOND
Practice Address - State:CA
Practice Address - Zip Code:95005-9702
Practice Address - Country:US
Practice Address - Phone:831-818-1934
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-06-19
Last Update Date:2022-06-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA403758163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
No163W00000XNursing Service ProvidersRegistered Nurse