MEDICARE: KELLYE SUSAN BRASSEL

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	RN506393	CA

General Provider Information

NPI Number	:	1992961767
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	KELLYE SUSAN BRASSEL

Provider Business Mailing Address
First Line	:	7425 RANCHO LOS GUILICOS RD
Second Line	:
City	:	SANTA ROSA
State	:	CA
Zip	:	95409-6519
Country	:	US
Telephone Number	:	707-565-6387
Fax Number	:

Provider Business Practice Location Address
First Line	:	7425 RANCHO LOS GUILICOS RD
Second Line	:
City	:	SANTA ROSA
State	:	CA
Zip	:	95409-6519
Country	:	US
Telephone Number	:	707-565-6387
Fax Number	:

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

Provider Enumeration Date	:	07/31/2008
Last Update Date	:	06/26/2014

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