Healthcare Provider Details

I. General information

NPI: 1487327979
Provider Name (Legal Business Name): NAOMI KERUBO BOGONKO RN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/29/2021
Last Update Date: 07/29/2021
Certification Date: 07/29/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1606 DANTE CIR
ROSEVILLE CA
95678-2935
US

IV. Provider business mailing address

1606 DANTE CIR
ROSEVILLE CA
95678-2935
US

V. Phone/Fax

Practice location:
  • Phone: 626-298-0405
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WM0705X
TaxonomyMedical-Surgical Registered Nurse
License Number95185392
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: