Provider Demographics
NPI:1720973571
Name:MOELJADI, BRENNA
Entity type:Individual
Prefix:
First Name:BRENNA
Middle Name:
Last Name:MOELJADI
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4555 STROHM AVE
Mailing Address - Street 2:
Mailing Address - City:TOLUCA LAKE
Mailing Address - State:CA
Mailing Address - Zip Code:91602-1515
Mailing Address - Country:US
Mailing Address - Phone:310-922-5860
Mailing Address - Fax:
Practice Address - Street 1:2299 POST ST STE 207
Practice Address - Street 2:
Practice Address - City:SAN FRANCISCO
Practice Address - State:CA
Practice Address - Zip Code:94115-3473
Practice Address - Country:US
Practice Address - Phone:415-530-5335
Practice Address - Fax:415-530-5336
Is Sole Proprietor?:Yes
Enumeration Date:2025-06-11
Last Update Date:2025-06-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant