Provider Demographics
NPI:1659930485
Name:MEDILO, LOVELLA (NP)
Entity Type:Individual
Prefix:
First Name:LOVELLA
Middle Name:
Last Name:MEDILO
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5395 RUFFIN RD STE 204
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92123-1338
Mailing Address - Country:US
Mailing Address - Phone:858-571-3630
Mailing Address - Fax:858-295-3948
Practice Address - Street 1:5395 RUFFIN RD STE 204
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92123-1338
Practice Address - Country:US
Practice Address - Phone:858-571-3630
Practice Address - Fax:858-295-3948
Is Sole Proprietor?:No
Enumeration Date:2019-06-05
Last Update Date:2024-04-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PASP020368363LP2300X
CA95010904363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No363LP2300XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPrimary Care