MEDICARE: RICHELLE BORNALES

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	163W00000X	Registered Nurse	95335432	CA
2	163WM0705X	Medical-Surgical Registered Nurse	95335432	CA
3	390200000X	Student in an Organized Health Care Education/Training Program

General Provider Information

NPI Number	:	1295572436
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	RICHELLE BORNALES

Provider Business Mailing Address
First Line	:	3912 RUSTIC LN
Second Line	:
City	:	VACAVILLE
State	:	CA
Zip	:	95688-9762
Country	:	US
Telephone Number	:	917-513-7667
Fax Number	:

Provider Business Practice Location Address
First Line	:	3912 RUSTIC LN
Second Line	:
City	:	VACAVILLE
State	:	CA
Zip	:	95688-9762
Country	:	US
Telephone Number	:	917-513-7667
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	07/15/2024
Last Update Date	:	07/15/2024

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Directions to “ RICHELLE BORNALES ” Practice Location

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