Healthcare Provider Details

I. General information

NPI: 1073074290
Provider Name (Legal Business Name): MARY ANNELISE RASMUSSEN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/29/2019
Last Update Date: 08/25/2025
Certification Date: 08/25/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4860 Y ST STE 3850
SACRAMENTO CA
95817-2307
US

IV. Provider business mailing address

4860 Y ST STE 3850
SACRAMENTO CA
95817-2307
US

V. Phone/Fax

Practice location:
  • Phone: 916-734-5293
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberA180647
License Number StateCA
# 2
Primary TaxonomyY
Taxonomy Code2081P0010X
TaxonomyPediatric Rehabilitation Medicine Physician
License NumberA180647
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: