Provider Demographics
NPI:1730714007
Name:CARABALLO, JULISSA LEONIDES (NP)
Entity type:Individual
Prefix:
First Name:JULISSA
Middle Name:LEONIDES
Last Name:CARABALLO
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4044 PROMONTORY ST
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92109-5334
Mailing Address - Country:US
Mailing Address - Phone:917-757-2230
Mailing Address - Fax:
Practice Address - Street 1:4044 PROMONTORY ST
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92109-5334
Practice Address - Country:US
Practice Address - Phone:917-757-2230
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-03-07
Last Update Date:2020-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA95005201363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health