Healthcare Provider Details

I. General information

NPI: 1356997050
Provider Name (Legal Business Name): GLENN GABRANG
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/18/2019
Last Update Date: 08/18/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1600 W AVENUE J
LANCASTER CA
93534-2894
US

IV. Provider business mailing address

39967 PENINA WAY
PALMDALE CA
93551-7534
US

V. Phone/Fax

Practice location:
  • Phone: 661-949-5000
  • Fax:
Mailing address:
  • Phone: 818-263-0737
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WP0809X
TaxonomyAdult Psychiatric/Mental Health Registered Nurse
License Number95125381
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: