Healthcare Provider Details

I. General information

NPI: 1689633455
Provider Name (Legal Business Name): MARYANN NUESSE D.O.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/21/2006
Last Update Date: 06/25/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

867 S TUSTIN ST
ORANGE CA
92866-3426
US

IV. Provider business mailing address

867 S TUSTIN ST
ORANGE CA
92866-3426
US

V. Phone/Fax

Practice location:
  • Phone: 714-771-1420
  • Fax: 714-771-6918
Mailing address:
  • Phone: 714-771-1420
  • Fax: 714-771-6918

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207QA0505X
TaxonomyAdult Medicine Physician
License Number20A7305
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: