Healthcare Provider Details

I. General information

NPI: 1407068059
Provider Name (Legal Business Name): MARJORIE SHELTON-GROSS
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/04/2007
Last Update Date: 12/01/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1469 HUMBOLDT RD SUITE 200
CHICO CA
95928-9116
US

IV. Provider business mailing address

1442 ETHAN WAY SUITE 200
SACRAMENTO CA
95825-2231
US

V. Phone/Fax

Practice location:
  • Phone: 530-891-1917
  • Fax:
Mailing address:
  • Phone: 916-481-8600
  • Fax: 916-481-9636

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207VH0002X
TaxonomyHospice and Palliative Medicine (Obstetrics & Gynecology) Physician
License NumberG455730
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: