Provider Demographics
NPI:1861739690
Name:PE, KATELYN PASSEY (NP)
Entity type:Individual
Prefix:MRS
First Name:KATELYN
Middle Name:PASSEY
Last Name:PE
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:KATELYN
Other - Middle Name:A
Other - Last Name:PASSEY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:NP
Mailing Address - Street 1:4060 FOURTH AVE
Mailing Address - Street 2:SUITE 240
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92103-2116
Mailing Address - Country:US
Mailing Address - Phone:619-291-2687
Mailing Address - Fax:619-291-3492
Practice Address - Street 1:4060 FOURTH AVE
Practice Address - Street 2:SUITE 240
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92103-2116
Practice Address - Country:US
Practice Address - Phone:619-291-2687
Practice Address - Fax:619-291-3492
Is Sole Proprietor?:No
Enumeration Date:2013-01-14
Last Update Date:2013-01-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA793963364SA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes364SA2200XPhysician Assistants & Advanced Practice Nursing ProvidersClinical Nurse SpecialistAdult Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA21263OtherNURSE PRACTITIONER