Healthcare Provider Details

I. General information

NPI: 1275802100
Provider Name (Legal Business Name): MARYA E GROSSE FNP
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/21/2011
Last Update Date: 12/21/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6 TARMAN DR
CLOVERDALE CA
95425-3932
US

IV. Provider business mailing address

100 W 3RD ST
CLOVERDALE CA
95425-3204
US

V. Phone/Fax

Practice location:
  • Phone: 707-894-4229
  • Fax: 707-894-2954
Mailing address:
  • Phone: 707-894-4229
  • Fax: 707-894-7820

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number528925
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: