Provider Demographics
NPI:1164862991
Name:GAVAGAN, JANELLE M (RN)
Entity Type:Individual
Prefix:
First Name:JANELLE
Middle Name:M
Last Name:GAVAGAN
Suffix:
Gender:F
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5353 BALTIMORE DR APT 90
Mailing Address - Street 2:
Mailing Address - City:LA MESA
Mailing Address - State:CA
Mailing Address - Zip Code:91942-4631
Mailing Address - Country:US
Mailing Address - Phone:442-222-4865
Mailing Address - Fax:
Practice Address - Street 1:730 MEDICAL CENTER CT
Practice Address - Street 2:
Practice Address - City:CHULA VISTA
Practice Address - State:CA
Practice Address - Zip Code:91911-6618
Practice Address - Country:US
Practice Address - Phone:619-397-6913
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-06-25
Last Update Date:2013-06-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA832833163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse