Healthcare Provider Details

I. General information

NPI: 1619521507
Provider Name (Legal Business Name): ANNABELLE JIMENEZ GOMEZ-BOGNOT REGISTERED NURSE
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/29/2019
Last Update Date: 07/29/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5901 E 7TH ST
LONG BEACH CA
90822-5201
US

IV. Provider business mailing address

7785 11TH ST
BUENA PARK CA
90621-3450
US

V. Phone/Fax

Practice location:
  • Phone: 562-826-5603
  • Fax:
Mailing address:
  • Phone: 628-268-0005
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WP0809X
TaxonomyAdult Psychiatric/Mental Health Registered Nurse
License Number633472
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: