Provider Demographics
NPI:1659574622
Name:BRATT, MAYA TRUJILLO (FNP)
Entity Type:Individual
Prefix:
First Name:MAYA
Middle Name:TRUJILLO
Last Name:BRATT
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:
Other - First Name:MAYA
Other - Middle Name:BETTY
Other - Last Name:RICE-TRUJILLO
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 743749
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90074-3749
Mailing Address - Country:US
Mailing Address - Phone:628-206-8000
Mailing Address - Fax:
Practice Address - Street 1:1001 POTRERO AVE
Practice Address - Street 2:BLDG. 80, WARD 83, RM 320
Practice Address - City:SAN FRANCISCO
Practice Address - State:CA
Practice Address - Zip Code:94110-3518
Practice Address - Country:US
Practice Address - Phone:628-206-8610
Practice Address - Fax:628-206-8387
Is Sole Proprietor?:No
Enumeration Date:2007-06-07
Last Update Date:2024-03-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA16651363LF0000X
CA641697363LW0102X
OR201603630NP-PP363LW0102X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LW0102XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerWomen's Health
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA1659574622Medicaid