Provider Demographics
NPI:1932938628
Name:GORHAM, CARRIE
Entity type:Individual
Prefix:
First Name:CARRIE
Middle Name:
Last Name:GORHAM
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 1:27625 STANFORD DR
Mailing Address - Street 2:
Mailing Address - City:TEMECULA
Mailing Address - State:CA
Mailing Address - Zip Code:92591-2849
Mailing Address - Country:US
Mailing Address - Phone:909-816-3645
Mailing Address - Fax:
Practice Address - Street 1:26439 YNEZ RD STE B
Practice Address - Street 2:
Practice Address - City:TEMECULA
Practice Address - State:CA
Practice Address - Zip Code:92591-5621
Practice Address - Country:US
Practice Address - Phone:909-816-3645
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-07-30
Last Update Date:2024-07-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAL8424374700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes374700000XNursing Service Related ProvidersTechnician