Healthcare Provider Details

I. General information

NPI: 1255456620
Provider Name (Legal Business Name): TRACI RENEE VARGAS NP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: TRACI RENEE GORMAN RN

II. Dates (important events)

Enumeration Date: 03/21/2007
Last Update Date: 06/06/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10418 VALLEY BLVD
EL MONTE CA
91731-3600
US

IV. Provider business mailing address

10418 VALLEY BLVD
EL MONTE CA
91731-3600
US

V. Phone/Fax

Practice location:
  • Phone: 626-453-8466
  • Fax: 626-453-8465
Mailing address:
  • Phone: 626-453-8466
  • Fax: 626-453-8465

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number462956
License Number StateCA
# 2
Primary TaxonomyY
Taxonomy Code363LW0102X
TaxonomyWomen's Health Nurse Practitioner
License Number16153
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: