Healthcare Provider Details

I. General information

NPI: 1093146243
Provider Name (Legal Business Name): ANDREA COURTNEY RUYBAL RN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/12/2013
Last Update Date: 12/12/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2101 COURAGE DR
FAIRFIELD CA
94533-6717
US

IV. Provider business mailing address

2101 COURAGE DR
FAIRFIELD CA
94533-6717
US

V. Phone/Fax

Practice location:
  • Phone: 707-750-3000
  • Fax: 707-673-5988
Mailing address:
  • Phone: 707-750-3000
  • Fax: 707-673-5988

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WG0000X
TaxonomyGeneral Practice Registered Nurse
License Number839194
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code163WP0808X
TaxonomyPsychiatric/Mental Health Registered Nurse
License Number839194
License Number StateCA
# 3
Primary TaxonomyN
Taxonomy Code163WS0200X
TaxonomySchool Registered Nurse
License Number839194
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: