Provider Demographics
NPI:1528684164
Name:FITZGERALD, MICHELLE LATICIA
Entity type:Individual
Prefix:MS
First Name:MICHELLE
Middle Name:LATICIA
Last Name:FITZGERALD
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 1:5631 ADOBE FALLS RD UNIT B
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92120-4656
Mailing Address - Country:US
Mailing Address - Phone:619-382-5674
Mailing Address - Fax:
Practice Address - Street 1:5631 ADOBE FALLS RD UNIT B
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92120-4656
Practice Address - Country:US
Practice Address - Phone:619-382-5674
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-06-19
Last Update Date:2020-06-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3747A0650XNursing Service Related ProvidersTechnicianAttendant Care Provider
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAB7131883OtherDRIVER LICENSE