Healthcare Provider Details

I. General information

NPI: 1710669817
Provider Name (Legal Business Name): MARTHA M HUACON RN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: MARTHA M DE LA VEGA

II. Dates (important events)

Enumeration Date: 08/07/2023
Last Update Date: 08/07/2023
Certification Date: 08/07/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

500 CROWN POINT CIR
GRASS VALLEY CA
95945-9561
US

IV. Provider business mailing address

14319 KNOBCONE DR
PENN VALLEY CA
95946-9519
US

V. Phone/Fax

Practice location:
  • Phone: 530-470-2408
  • Fax:
Mailing address:
  • Phone: 530-329-6156
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WP0809X
TaxonomyAdult Psychiatric/Mental Health Registered Nurse
License Number95125466
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: