Provider Demographics
NPI:1942251319
Name:CARSON, ANN KATHRYN (PHD)
Entity Type:Individual
Prefix:DR
First Name:ANN
Middle Name:KATHRYN
Last Name:CARSON
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9261 FULLERTON AVE
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92123-3146
Mailing Address - Country:US
Mailing Address - Phone:619-516-0221
Mailing Address - Fax:858-496-9782
Practice Address - Street 1:9261 FULLERTON AVE
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92123-3146
Practice Address - Country:US
Practice Address - Phone:619-516-0221
Practice Address - Fax:858-496-9782
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-12
Last Update Date:2016-10-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPSY12884103TC0700X
CAR213694163W00000X
CA1477363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
No163W00000XNursing Service ProvidersRegistered Nurse
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA330490987 92108 A001OtherTRICARE
CAOPL128840OtherBLUE SHIELD
CA183091OtherMANAGED HEALTH NETWORK
CAPSY128840Medicaid
CAPSY128840Medicaid
CACP12884Medicare ID - Type Unspecified