Healthcare Provider Details

I. General information

NPI: 1689126278
Provider Name (Legal Business Name): GINA ANDERSON
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/29/2016
Last Update Date: 02/11/2022
Certification Date: 10/05/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4327 GOLDEN CENTER DR
PLACERVILLE CA
95667-6287
US

IV. Provider business mailing address

3701 J ST STE 109
SACRAMENTO CA
95816-5542
US

V. Phone/Fax

Practice location:
  • Phone: 530-621-7700
  • Fax: 530-621-7713
Mailing address:
  • Phone: 530-621-7700
  • Fax: 530-621-7713

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number95005147
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: