Provider Demographics
NPI:1669568374
Name:BERNABE, PRIMA BERNABE (MPT)
Entity type:Individual
Prefix:
First Name:PRIMA
Middle Name:BERNABE
Last Name:BERNABE
Suffix:
Gender:F
Credentials:MPT
Other - Prefix:
Other - First Name:LAPRIMA
Other - Middle Name:BERNABE
Other - Last Name:WOOTERS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MPT
Mailing Address - Street 1:5745 FRIARS RD
Mailing Address - Street 2:UNIT 106
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92110-1828
Mailing Address - Country:US
Mailing Address - Phone:858-353-3800
Mailing Address - Fax:888-353-3668
Practice Address - Street 1:11555 SCRIPPS LAKE DRIVE
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92131
Practice Address - Country:US
Practice Address - Phone:858-353-3800
Practice Address - Fax:888-353-3668
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-04
Last Update Date:2016-06-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA25254225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA610787900OtherDEPARTMENT OF LABOR
CAZZZ66632ZOtherBLUE SHIELD
CA2190632OtherFIRST HEALTH
CAZZZ66632ZOtherBLUE SHIELD