Provider Demographics
NPI:1750683314
Name:VAN LOGGEM, BRENDA GERALDINE (NP)
Entity Type:Individual
Prefix:
First Name:BRENDA
Middle Name:GERALDINE
Last Name:VAN LOGGEM
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:31570 EAGLE ROCK WAY
Mailing Address - Street 2:
Mailing Address - City:LAGUNA BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:92651-8299
Mailing Address - Country:US
Mailing Address - Phone:949-715-0464
Mailing Address - Fax:949-715-0464
Practice Address - Street 1:6920 MIRAMAR RD
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92121-2632
Practice Address - Country:US
Practice Address - Phone:858-935-7379
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-12-02
Last Update Date:2010-12-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA589781363LG0600X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LG0600XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGerontology