Provider Demographics
NPI:1780024588
Name:WASIMI, FAZELA (NP)
Entity Type:Individual
Prefix:
First Name:FAZELA
Middle Name:
Last Name:WASIMI
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 1:7946 LAKE ADLON DR
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92119-3117
Mailing Address - Country:US
Mailing Address - Phone:619-303-0497
Mailing Address - Fax:619-330-4782
Practice Address - Street 1:4692 MISSION BLVD
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92109-2734
Practice Address - Country:US
Practice Address - Phone:619-647-5072
Practice Address - Fax:619-330-4782
Is Sole Proprietor?:No
Enumeration Date:2013-06-26
Last Update Date:2016-03-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA696952163W00000X
CA22375364SF0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes364SF0001XPhysician Assistants & Advanced Practice Nursing ProvidersClinical Nurse SpecialistFamily Health
No163W00000XNursing Service ProvidersRegistered Nurse