Provider Demographics
NPI:1942021696
Name:BRACAMONTES, RAQUEL (PMHNP)
Entity type:Individual
Prefix:
First Name:RAQUEL
Middle Name:
Last Name:BRACAMONTES
Suffix:
Gender:F
Credentials:PMHNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2516 LINCOLN BLVD
Mailing Address - Street 2:
Mailing Address - City:VENICE
Mailing Address - State:CA
Mailing Address - Zip Code:90291-5043
Mailing Address - Country:US
Mailing Address - Phone:626-230-8431
Mailing Address - Fax:
Practice Address - Street 1:2516 LINCOLN BLVD
Practice Address - Street 2:
Practice Address - City:VENICE
Practice Address - State:CA
Practice Address - Zip Code:90291-5043
Practice Address - Country:US
Practice Address - Phone:626-230-8431
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-10-24
Last Update Date:2024-10-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA95032687363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health