Healthcare Provider Details

I. General information

NPI: 1962619387
Provider Name (Legal Business Name): MARY ROSENTHAL
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/16/2007
Last Update Date: 09/11/2025
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

120 W FIR ST
FORT BRAGG CA
95437-3204
US

IV. Provider business mailing address

120 W FIR ST
FORT BRAGG CA
95437-3204
US

V. Phone/Fax

Practice location:
  • Phone: 707-921-2619
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code364S00000X
TaxonomyClinical Nurse Specialist
License NumberRN271105
License Number StateCA
# 2
Primary TaxonomyY
Taxonomy Code364SC1501X
TaxonomyCommunity Health/Public Health Clinical Nurse Specialist
License NumberRN271105
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: