Healthcare Provider Details

I. General information

NPI: 1457190472
Provider Name (Legal Business Name): ISABELLA AMYTHYST PARKS
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: ISABELLA AMYTHYST RUSS

II. Dates (important events)

Enumeration Date: 05/20/2024
Last Update Date: 04/13/2025
Certification Date: 04/13/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

333 CROWN POINT CIR
GRASS VALLEY CA
95945-9534
US

IV. Provider business mailing address

500 CROWN POINT CIR
GRASS VALLEY CA
95945-9561
US

V. Phone/Fax

Practice location:
  • Phone: 530-273-5440
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code372600000X
TaxonomyAdult Companion
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code172V00000X
TaxonomyCommunity Health Worker
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: