Provider Demographics
NPI:1982240420
Name:CALLEROS, CARLYNNE RIVERA (FNP-BC)
Entity Type:Individual
Prefix:
First Name:CARLYNNE
Middle Name:RIVERA
Last Name:CALLEROS
Suffix:
Gender:F
Credentials:FNP-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3825 RIVIERA DR APT 1
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92109-6333
Mailing Address - Country:US
Mailing Address - Phone:619-922-5591
Mailing Address - Fax:
Practice Address - Street 1:765 MEDICAL CENTER CT STE 218
Practice Address - Street 2:
Practice Address - City:CHULA VISTA
Practice Address - State:CA
Practice Address - Zip Code:91911-6600
Practice Address - Country:US
Practice Address - Phone:619-841-7089
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-11-19
Last Update Date:2019-11-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA95013305363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily