Healthcare Provider Details

I. General information

NPI: 1609614270
Provider Name (Legal Business Name): BRENDA OLMOS RN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/18/2024
Last Update Date: 07/18/2024
Certification Date: 07/17/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1116 W LINDEN ST APT 203
RIVERSIDE CA
92507-3872
US

IV. Provider business mailing address

1116 W LINDEN ST APT 203
RIVERSIDE CA
92507-3872
US

V. Phone/Fax

Practice location:
  • Phone: 951-544-0176
  • Fax:
Mailing address:
  • Phone: 951-544-0176
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number95366863
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: