Provider Demographics
NPI:1871058727
Name:LANNEN, GINA THERESA (ATC, CSCS)
Entity type:Individual
Prefix:MRS
First Name:GINA
Middle Name:THERESA
Last Name:LANNEN
Suffix:
Gender:F
Credentials:ATC, CSCS
Other - Prefix:
Other - First Name:GINA
Other - Middle Name:THERESA
Other - Last Name:MAGGIO
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:ATC, CSCS
Mailing Address - Street 1:9073 COVINA ST
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92126-3717
Mailing Address - Country:US
Mailing Address - Phone:619-865-3219
Mailing Address - Fax:
Practice Address - Street 1:1600 HENDERSON AVE BLDG 573
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92140-5000
Practice Address - Country:US
Practice Address - Phone:619-524-4101
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-02-05
Last Update Date:2019-02-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA0300020482255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer