MEDICARE: MS. GRACE ANITA SORENSON RN BSN

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	163W00000X	Registered Nurse	RN95215971	CA

General Provider Information

NPI Number	:	1417584384
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MS. GRACE ANITA SORENSON RN BSN

Provider Business Mailing Address
First Line	:	1023 BROMMER ST
Second Line	:
City	:	SANTA CRUZ
State	:	CA
Zip	:	95062-2807
Country	:	US
Telephone Number	:	925-348-5443
Fax Number	:

Provider Business Practice Location Address
First Line	:	1023 BROMMER ST
Second Line	:
City	:	SANTA CRUZ
State	:	CA
Zip	:	95062-2807
Country	:	US
Telephone Number	:	925-348-5443
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	03/23/2020
Last Update Date	:	03/23/2020

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