Provider Demographics
NPI:1790408946
Name:CAMACHO, ALAN JAMES (PMHNP)
Entity Type:Individual
Prefix:
First Name:ALAN
Middle Name:JAMES
Last Name:CAMACHO
Suffix:
Gender:M
Credentials:PMHNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:621 CASA DE LEON
Mailing Address - Street 2:
Mailing Address - City:REDLANDS
Mailing Address - State:CA
Mailing Address - Zip Code:92373-5787
Mailing Address - Country:US
Mailing Address - Phone:909-435-5787
Mailing Address - Fax:
Practice Address - Street 1:9479 HAVEN AVE
Practice Address - Street 2:
Practice Address - City:RANCHO CUCAMONGA
Practice Address - State:CA
Practice Address - Zip Code:91730-5844
Practice Address - Country:US
Practice Address - Phone:909-771-8023
Practice Address - Fax:909-658-8977
Is Sole Proprietor?:No
Enumeration Date:2022-09-22
Last Update Date:2022-09-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA95053159163WG0000X
CA95022516363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
No163WG0000XNursing Service ProvidersRegistered NurseGeneral Practice