Healthcare Provider Details

I. General information

NPI: 1770002990
Provider Name (Legal Business Name): GANIAT A GBADEBO NP
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/19/2017
Last Update Date: 01/29/2020
Certification Date: 01/29/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1328 S MISSION RD
FALLBROOK CA
92028-4006
US

IV. Provider business mailing address

1328 S MISSION RD
FALLBROOK CA
92028-4006
US

V. Phone/Fax

Practice location:
  • Phone: 760-451-4720
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number95006183
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: