Healthcare Provider Details

I. General information

NPI: 1851614887
Provider Name (Legal Business Name): JUDITH GRIFFIN NP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/04/2010
Last Update Date: 10/26/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

280 SIERRA COLLEGE DR STE 120
GRASS VALLEY CA
95945-5763
US

IV. Provider business mailing address

3400 DATA DR ATTN: CREDENTIALING/PAYER ENROLLMENT
RANCHO CORDOVA CA
95670-7956
US

V. Phone/Fax

Practice location:
  • Phone: 530-477-4480
  • Fax: 530-274-7532
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LA2200X
TaxonomyAdult Health Nurse Practitioner
License Number19155
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number661214
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: