Healthcare Provider Details

I. General information

NPI: 1952937658
Provider Name (Legal Business Name): MARIAM GBATY SOUMAHORO
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/14/2020
Last Update Date: 03/14/2020
Certification Date: 03/14/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3800 SILVER SPUR WAY
SACRAMENTO CA
95841-4411
US

IV. Provider business mailing address

3800 SILVER SPUR WAY
SACRAMENTO CA
95841-4411
US

V. Phone/Fax

Practice location:
  • Phone: 916-904-0027
  • Fax:
Mailing address:
  • Phone: 916-904-0027
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code310400000X
TaxonomyAssisted Living Facility
License Number342700506
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code163WC1500X
TaxonomyCommunity Health Registered Nurse
License Number783011
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: