Healthcare Provider Details

I. General information

NPI: 1326574963
Provider Name (Legal Business Name): GWEN ANNE BRUSH LVN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/02/2017
Last Update Date: 12/08/2021
Certification Date: 12/08/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2060 CAMPUS DR
YREKA CA
96097-9538
US

IV. Provider business mailing address

441 N MAIN ST
ALTURAS CA
96101-3457
US

V. Phone/Fax

Practice location:
  • Phone: 530-841-4100
  • Fax:
Mailing address:
  • Phone: 530-233-6312
  • Fax: 530-233-6339

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code164X00000X
TaxonomyLicensed Vocational Nurse
License NumberVN269012
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: