Healthcare Provider Details

I. General information

NPI: 1770168353
Provider Name (Legal Business Name): BRENDA VILLAGONZALO GEBALA
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/15/2021
Last Update Date: 03/15/2021
Certification Date: 03/12/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

14401 HARTSOOK ST
SHERMAN OAKS CA
91423-1022
US

IV. Provider business mailing address

14401 HARTSOOK ST APT 310
SHERMAN OAKS CA
91423-1041
US

V. Phone/Fax

Practice location:
  • Phone: 407-497-6808
  • Fax:
Mailing address:
  • Phone: 407-497-6808
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number95146639
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: