Provider Demographics
NPI:1215297866
Name:HART, DEANNDRA DONNETTE
Entity type:Individual
Prefix:
First Name:DEANNDRA
Middle Name:DONNETTE
Last Name:HART
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4512 OREGON ST
Mailing Address - Street 2:#7
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92116-4919
Mailing Address - Country:US
Mailing Address - Phone:619-997-7022
Mailing Address - Fax:
Practice Address - Street 1:4512 OREGON ST
Practice Address - Street 2:#7
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92116-4919
Practice Address - Country:US
Practice Address - Phone:619-997-7022
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-05-16
Last Update Date:2012-05-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA989225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist