Healthcare Provider Details

I. General information

NPI: 1609269927
Provider Name (Legal Business Name): ABBY STRETCH
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/11/2015
Last Update Date: 10/29/2020
Certification Date: 10/29/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4010 FOOTHILLS BLVD STE 102
ROSEVILLE CA
95747-7241
US

IV. Provider business mailing address

PO BOX 255228
SACRAMENTO CA
95865-5228
US

V. Phone/Fax

Practice location:
  • Phone: 800-972-5547
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License Number52322
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: