Provider Demographics
NPI:1639636004
Name:DAGHLIAN, DENNAFAYE (PA-C)
Entity Type:Individual
Prefix:
First Name:DENNAFAYE
Middle Name:
Last Name:DAGHLIAN
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:DENNAFAYE
Other - Middle Name:
Other - Last Name:HERALD
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA
Mailing Address - Street 1:10790 RANCHO BERNARDO RD # 4S-205
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92127-5705
Mailing Address - Country:US
Mailing Address - Phone:858-605-7171
Mailing Address - Fax:
Practice Address - Street 1:15004 INNOVATION DR
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92128-3498
Practice Address - Country:US
Practice Address - Phone:858-605-7837
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-02-21
Last Update Date:2022-03-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA56534363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant