Provider Demographics
NPI:1477844017
Name:REA, BRENDA LYNN (MD)
Entity type:Individual
Prefix:
First Name:BRENDA
Middle Name:LYNN
Last Name:REA
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:25455 BARTON RD STE 206A
Mailing Address - Street 2:
Mailing Address - City:LOMA LINDA
Mailing Address - State:CA
Mailing Address - Zip Code:92354-3130
Mailing Address - Country:US
Mailing Address - Phone:909-558-6688
Mailing Address - Fax:
Practice Address - Street 1:25455 BARTON RD STE 206A
Practice Address - Street 2:
Practice Address - City:LOMA LINDA
Practice Address - State:CA
Practice Address - Zip Code:92354-3130
Practice Address - Country:US
Practice Address - Phone:909-558-6688
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-05-01
Last Update Date:2023-07-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GUM-1913207Q00000X
CAA122437207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine