Provider Demographics
NPI:1326190133
Name:DEFREITAS, DEANNA LYNN
Entity type:Individual
Prefix:MRS
First Name:DEANNA
Middle Name:LYNN
Last Name:DEFREITAS
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 1:4662 LUCILLE DR
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92115-1935
Mailing Address - Country:US
Mailing Address - Phone:619-286-8538
Mailing Address - Fax:
Practice Address - Street 1:4662 LUCILLE DR
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92115-1935
Practice Address - Country:US
Practice Address - Phone:619-286-8538
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-18
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAC571894172A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172A00000XOther Service ProvidersDriver