Healthcare Provider Details

I. General information

NPI: 1104790286
Provider Name (Legal Business Name): SUSANA ASHBY
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/01/2025
Last Update Date: 10/01/2025
Certification Date: 10/01/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2633 E 27TH ST
OAKLAND CA
94601-1912
US

IV. Provider business mailing address

2633 E 27TH ST
OAKLAND CA
94601-1912
US

V. Phone/Fax

Practice location:
  • Phone: 510-535-5115
  • Fax:
Mailing address:
  • Phone: 510-535-5115
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License Number95209441
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: