Healthcare Provider Details

I. General information

NPI: 1336090471
Provider Name (Legal Business Name): MARISELLA FUSTAMANTE CARRANZA
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/05/2026
Last Update Date: 02/05/2026
Certification Date: 02/05/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1001 POTRERO AVE
SAN FRANCISCO CA
94110-3518
US

IV. Provider business mailing address

1 HARRINGTON RD
MORAGA CA
94556-2814
US

V. Phone/Fax

Practice location:
  • Phone: 415-823-0176
  • Fax:
Mailing address:
  • Phone: 415-823-3005
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WW0101X
TaxonomyAmbulatory Women's Health Care Registered Nurse
License Number773064
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: