Healthcare Provider Details

I. General information

NPI: 1366277238
Provider Name (Legal Business Name): PREONA ST MARY
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/03/2024
Last Update Date: 08/20/2026
Certification Date: 08/20/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2150 STOCKTON BLVD
SACRAMENTO CA
95817-1337
US

IV. Provider business mailing address

3451 N FREEWAY BLVD
SACRAMENTO CA
95834-3928
US

V. Phone/Fax

Practice location:
  • Phone: 916-417-0438
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225400000X
TaxonomyRehabilitation Practitioner
License Number
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: