Healthcare Provider Details

I. General information

NPI: 1962487710
Provider Name (Legal Business Name): MARY KAY OSBORN FNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: MARY KAY WEBB

II. Dates (important events)

Enumeration Date: 12/14/2005
Last Update Date: 07/17/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1095 MARSHALL WAY
PLACERVILLE CA
95667-5722
US

IV. Provider business mailing address

1095 MARSHALL WAY
PLACERVILLE CA
95667-6533
US

V. Phone/Fax

Practice location:
  • Phone: 530-626-2920
  • Fax: 530-626-2974
Mailing address:
  • Phone: 530-626-2920
  • Fax: 530-626-2974

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License NumberNP4926
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License NumberRN319014
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: