Provider Demographics
NPI:1215789094
Name:MORES, BRENDA (FNP)
Entity type:Individual
Prefix:
First Name:BRENDA
Middle Name:
Last Name:MORES
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 6364
Mailing Address - Street 2:
Mailing Address - City:TAHOE CITY
Mailing Address - State:CA
Mailing Address - Zip Code:96145-6364
Mailing Address - Country:US
Mailing Address - Phone:530-363-7016
Mailing Address - Fax:
Practice Address - Street 1:3101 LAKE FOREST RD
Practice Address - Street 2:
Practice Address - City:TAHOE CITY
Practice Address - State:CA
Practice Address - Zip Code:96145-2336
Practice Address - Country:US
Practice Address - Phone:530-363-7016
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-04-03
Last Update Date:2024-04-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA95029625363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily