Provider Demographics
NPI:1497412761
Name:BOCANEGRA, BRYANNA
Entity Type:Individual
Prefix:
First Name:BRYANNA
Middle Name:
Last Name:BOCANEGRA
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 1:1516 N BROADWAY
Mailing Address - Street 2:
Mailing Address - City:ESCONDIDO
Mailing Address - State:CA
Mailing Address - Zip Code:92026-2016
Mailing Address - Country:US
Mailing Address - Phone:760-402-7974
Mailing Address - Fax:
Practice Address - Street 1:1516 N BROADWAY
Practice Address - Street 2:
Practice Address - City:ESCONDIDO
Practice Address - State:CA
Practice Address - Zip Code:92026-2016
Practice Address - Country:US
Practice Address - Phone:760-402-7974
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-11-22
Last Update Date:2021-11-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer