Healthcare Provider Details

I. General information

NPI: 1356703078
Provider Name (Legal Business Name): THERESA WEST
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/22/2016
Last Update Date: 03/22/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12930 GASTON DR
NEVADA CITY CA
95959-9524
US

IV. Provider business mailing address

145 GLASSON WAY
GRASS VALLEY CA
95945
US

V. Phone/Fax

Practice location:
  • Phone: 530-470-2425
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code164W00000X
TaxonomyLicensed Practical Nurse
License NumberVN233284
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: