MEDICARE: TRACI JANE GRUSSENMEYER

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	363LF0000X	Family Nurse Practitioner	95010232	CA
2	363A00000X	Physician Assistant	56099	CA

General Provider Information

NPI Number	:	1770058521
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	TRACI JANE GRUSSENMEYER

Provider Business Mailing Address
First Line	:	PO BOX 255228
Second Line	:
City	:	SACRAMENTO
State	:	CA
Zip	:	95865-5228
Country	:	US
Telephone Number	:	800-470-0071
Fax Number	:	916-854-6769

Provider Business Practice Location Address
First Line	:	1625 STOCKTON BLVD STE 104
Second Line	:
City	:	SACRAMENTO
State	:	CA
Zip	:	95816-7098
Country	:	US
Telephone Number	:	916-469-9337
Fax Number	:	916-706-3632

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

Provider Enumeration Date	:	10/08/2018
Last Update Date	:	02/23/2026

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Directions to “ TRACI JANE GRUSSENMEYER ” Practice Location

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