Provider Demographics
NPI:1922780667
Name:GOMEZ, BRENDA NA-----
Entity Type:Individual
Prefix:
First Name:BRENDA
Middle Name:NA-----
Last Name:GOMEZ
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:240 STEVENS AVE
Mailing Address - Street 2:
Mailing Address - City:LA HABRA
Mailing Address - State:CA
Mailing Address - Zip Code:90631-2920
Mailing Address - Country:US
Mailing Address - Phone:562-652-6971
Mailing Address - Fax:
Practice Address - Street 1:240 STEVENS AVE
Practice Address - Street 2:
Practice Address - City:LA HABRA
Practice Address - State:CA
Practice Address - Zip Code:90631-2920
Practice Address - Country:US
Practice Address - Phone:562-652-6971
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-08-02
Last Update Date:2023-08-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA95026374363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily