Healthcare Provider Details

I. General information

NPI: 1558670117
Provider Name (Legal Business Name): BRITTANY ANN TREVINO-GOMBAR FNP-BC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/30/2010
Last Update Date: 04/12/2022
Certification Date: 04/12/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3401 N 67TH AVE
PHOENIX AZ
85033-4517
US

IV. Provider business mailing address

3401 N 67TH AVE
PHOENIX AZ
85033-4517
US

V. Phone/Fax

Practice location:
  • Phone: 623-691-4085
  • Fax: 623-691-5924
Mailing address:
  • Phone: 623-691-4085
  • Fax: 623-691-5924

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number268330
License Number StateAZ
# 2
Primary TaxonomyN
Taxonomy Code164W00000X
TaxonomyLicensed Practical Nurse
License NumberLP046747
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: