Provider Demographics
NPI:1205206273
Name:GAUDIOSO-BROOKS, JOANNE
Entity Type:Individual
Prefix:
First Name:JOANNE
Middle Name:
Last Name:GAUDIOSO-BROOKS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:JOANNE
Other - Middle Name:
Other - Last Name:GAUDIOSO
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:NP
Mailing Address - Street 1:34525 MAHOGANY LN
Mailing Address - Street 2:
Mailing Address - City:UNION CITY
Mailing Address - State:CA
Mailing Address - Zip Code:94587-8010
Mailing Address - Country:US
Mailing Address - Phone:510-952-1458
Mailing Address - Fax:
Practice Address - Street 1:4131 GEARY BLVD FL 4
Practice Address - Street 2:
Practice Address - City:SAN FRANCISCO
Practice Address - State:CA
Practice Address - Zip Code:94118-3101
Practice Address - Country:US
Practice Address - Phone:415-741-4208
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-10-02
Last Update Date:2021-11-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA680150163W00000X
CA95004352363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No163W00000XNursing Service ProvidersRegistered Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA1205206273Medicaid