Provider Demographics
NPI:1821469321
Name:BRAMBILA, JACQUELINE (PA-C)
Entity Type:Individual
Prefix:
First Name:JACQUELINE
Middle Name:
Last Name:BRAMBILA
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8131 VANTAGE AVE
Mailing Address - Street 2:
Mailing Address - City:NORTH HOLLYWOOD
Mailing Address - State:CA
Mailing Address - Zip Code:91605-1438
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1617 WESTCLIFF DR
Practice Address - Street 2:SUITE 207
Practice Address - City:NEWPORT BEACH
Practice Address - State:CA
Practice Address - Zip Code:92660-5524
Practice Address - Country:US
Practice Address - Phone:949-515-4111
Practice Address - Fax:949-515-0318
Is Sole Proprietor?:Yes
Enumeration Date:2015-10-09
Last Update Date:2017-01-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA52924363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant