Healthcare Provider Details

I. General information

NPI: 1730275082
Provider Name (Legal Business Name): MARK LEE HUFFMAN RN
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/05/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12500 BRUCEVILLE RD
ELK GROVE CA
95757-9784
US

IV. Provider business mailing address

2636 CARMICHAEL WAY
CARMICHAEL CA
95608-5316
US

V. Phone/Fax

Practice location:
  • Phone: 916-874-1866
  • Fax: 916-874-1926
Mailing address:
  • Phone: 916-486-2636
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WP0808X
TaxonomyPsychiatric/Mental Health Registered Nurse
License NumberRN390870
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: