Healthcare Provider Details

I. General information

NPI: 1942021696
Provider Name (Legal Business Name): RAQUEL BRACAMONTES PMHNP
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/24/2024
Last Update Date: 08/21/2025
Certification Date: 08/21/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6809 INDIANA AVE STE 130-C22
RIVERSIDE CA
92506-4221
US

IV. Provider business mailing address

6809 INDIANA AVE STE 130-C22
RIVERSIDE CA
92506-4221
US

V. Phone/Fax

Practice location:
  • Phone: 951-633-8466
  • Fax:
Mailing address:
  • Phone: 951-633-8466
  • Fax: 650-403-1817

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number95032687
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: