Healthcare Provider Details

I. General information

NPI: 1558128702
Provider Name (Legal Business Name): MS. ELIZABETH RAE WIRTH
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/04/2024
Last Update Date: 10/18/2024
Certification Date: 10/18/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

900 FULTON AVE STE 205
SACRAMENTO CA
95825-4517
US

IV. Provider business mailing address

900 FULTON AVE
SACRAMENTO CA
95825-4500
US

V. Phone/Fax

Practice location:
  • Phone: 916-484-3570
  • Fax: 916-484-3577
Mailing address:
  • Phone: 916-484-3570
  • Fax: 916-484-3577

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code172V00000X
TaxonomyCommunity Health Worker
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code175T00000X
TaxonomyPeer Specialist
License NumberMPSS-OJSYXP
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: