Healthcare Provider Details

I. General information

NPI: 1750683314
Provider Name (Legal Business Name): BRENDA GERALDINE VAN LOGGEM NP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/02/2010
Last Update Date: 12/02/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6920 MIRAMAR RD
SAN DIEGO CA
92121-2632
US

IV. Provider business mailing address

31570 EAGLE ROCK WAY
LAGUNA BEACH CA
92651-8299
US

V. Phone/Fax

Practice location:
  • Phone: 858-935-7379
  • Fax:
Mailing address:
  • Phone: 949-715-0464
  • Fax: 949-715-0464

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LG0600X
TaxonomyGerontology Nurse Practitioner
License Number589781
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: