Provider Demographics
NPI:1558670117
Name:TREVINO-GOMBAR, BRITTANY ANN (FNP-BC)
Entity Type:Individual
Prefix:
First Name:BRITTANY
Middle Name:ANN
Last Name:TREVINO-GOMBAR
Suffix:
Gender:F
Credentials:FNP-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3401 N 67TH AVE
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85033-4517
Mailing Address - Country:US
Mailing Address - Phone:623-691-4085
Mailing Address - Fax:623-691-5924
Practice Address - Street 1:3401 N 67TH AVE
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85033-4517
Practice Address - Country:US
Practice Address - Phone:623-691-4085
Practice Address - Fax:623-691-5924
Is Sole Proprietor?:Yes
Enumeration Date:2010-09-30
Last Update Date:2022-04-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZLP046747164W00000X
AZ268330363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No164W00000XNursing Service ProvidersLicensed Practical Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ106863Medicaid