Healthcare Provider Details

I. General information

NPI: 1770058521
Provider Name (Legal Business Name): TRACI JANE GRUSSENMEYER
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: TRACI JANE POCHARDT

II. Dates (important events)

Enumeration Date: 10/08/2018
Last Update Date: 02/23/2026
Certification Date: 02/23/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1625 STOCKTON BLVD STE 104
SACRAMENTO CA
95816-7098
US

IV. Provider business mailing address

PO BOX 255228
SACRAMENTO CA
95865-5228
US

V. Phone/Fax

Practice location:
  • Phone: 916-469-9337
  • Fax: 916-706-3632
Mailing address:
  • Phone: 800-470-0071
  • Fax: 916-854-6769

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number56099
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number95010232
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: