Healthcare Provider Details

I. General information

NPI: 1134044423
Provider Name (Legal Business Name): CHEYENNE GAMBOA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/13/2026
Last Update Date: 08/13/2026
Certification Date: 08/13/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

818 W 24TH ST
SAN BERNARDINO CA
92405-3620
US

IV. Provider business mailing address

818 W 24TH ST
SAN BERNARDINO CA
92405-3620
US

V. Phone/Fax

Practice location:
  • Phone: 626-215-8595
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225X00000X
TaxonomyOccupational Therapist
License Number27896
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: