Basic Information
| Provider Information | |||||||||
| NPI: | 1508263815 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | GAMBALA | ||||||||
| FirstName: | VANESSA | ||||||||
| MiddleName: | TAGATAC | ||||||||
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| Credential: | NP | ||||||||
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| Mailing Information | |||||||||
| Address1: | 11230 SORRENTO VALLEY RD | ||||||||
| Address2: | SUITE 120 | ||||||||
| City: | SAN DIEGO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 921211332 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8585467600 | ||||||||
| FaxNumber: | 8584084281 | ||||||||
| Practice Location | |||||||||
| Address1: | 11230 SORRENTO VALLEY RD | ||||||||
| Address2: | SUITE 120 | ||||||||
| City: | SAN DIEGO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 921211332 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8585467600 | ||||||||
| FaxNumber: | 8584084281 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/02/2014 | ||||||||
| LastUpdateDate: | 12/02/2014 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 163W00000X | 584220 | CA | N | Nursing Service Providers | Registered Nurse | 363L00000X | 95000947 | CA | N | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | 363LA2200X | 95000947 | CA | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Adult Health |
No ID Information.