Healthcare Provider Details

I. General information

NPI: 1770058521
Provider Name (Legal Business Name): TRACI JANE GRUSSENMEYER
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/08/2018
Last Update Date: 10/09/2020
Certification Date: 10/09/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9300 VALLEY CHILDRENS PL # SC05
MADERA CA
93636-8761
US

IV. Provider business mailing address

3159 BERTIS DR
SACRAMENTO CA
95821-4453
US

V. Phone/Fax

Practice location:
  • Phone: 559-353-5700
  • Fax: 559-353-5708
Mailing address:
  • Phone: 480-250-9156
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number95010232
License Number StateCA
# 2
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number56099
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: