Basic Information
| Provider Information | |||||||||
| NPI: | 1326520107 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MINNOCCI | ||||||||
| FirstName: | MACY | ||||||||
| MiddleName: | KAITLYN | ||||||||
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| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | GOSS | ||||||||
| OtherFirstName: | MACY | ||||||||
| OtherMiddleName: | KAITLYN | ||||||||
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| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 11545 WINDCREST LN APT 193 | ||||||||
| Address2: | |||||||||
| City: | SAN DIEGO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 921284241 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4085948686 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 734 10TH AVE | ||||||||
| Address2: | |||||||||
| City: | SAN DIEGO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 921016502 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6192394663 | ||||||||
| FaxNumber: | 6192393045 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/29/2018 | ||||||||
| LastUpdateDate: | 08/29/2018 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 390200000X | Y | Student, Health Care | Student in an Organized Health Care Education/Training Program |
No ID Information.