MEDICARE: MS. BERNADETTE PAMULO GONZALES NURSE PRACTITIONER

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	363L00000X	Nurse Practitioner	NP 19702	CA
2	363LF0000X	Family Nurse Practitioner	F1208164	CA

General Provider Information

NPI Number	:	1346559317
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MS. BERNADETTE PAMULO GONZALES NURSE PRACTITIONER

Provider Business Mailing Address
First Line	:	197 N. MOHLER DRIVE
Second Line	:
City	:	ANAHEIM HILLS
State	:	CA
Zip	:	92808
Country	:	US
Telephone Number	:	714-998-7088
Fax Number	:

Provider Business Practice Location Address
First Line	:	197 N. MOHLER DRIVE
Second Line	:
City	:	ANAHEIM HILLS
State	:	CA
Zip	:	92808
Country	:	US
Telephone Number	:	714-998-7088
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	09/24/2010
Last Update Date	:	09/24/2010

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