Healthcare Provider Details

I. General information

NPI: 1811717366
Provider Name (Legal Business Name): JOSSELYNN ANNETTE BREWER
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: JOSSELYNN ANNETTE NOGO

II. Dates (important events)

Enumeration Date: 10/10/2024
Last Update Date: 10/10/2024
Certification Date: 10/10/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2460 MAIN ST
MORRO BAY CA
93442-1552
US

IV. Provider business mailing address

2460 MAIN ST
MORRO BAY CA
93442-1552
US

V. Phone/Fax

Practice location:
  • Phone: 805-772-2212
  • Fax:
Mailing address:
  • Phone: 805-772-2212
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code247200000X
TaxonomyOther Technician
License NumberR1569860724
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: