Provider Demographics
NPI:1740790724
Name:EICHERT, MARY LYNN ELIZABETH (NP)
Entity Type:Individual
Prefix:
First Name:MARY LYNN
Middle Name:ELIZABETH
Last Name:EICHERT
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 1:4328 MOUNT HUKEE AVE
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92117-4738
Mailing Address - Country:US
Mailing Address - Phone:704-516-6782
Mailing Address - Fax:
Practice Address - Street 1:5965 VILLAGE WAY STE E207
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92130-2475
Practice Address - Country:US
Practice Address - Phone:619-293-7233
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-10-04
Last Update Date:2017-10-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA95005931363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily