Healthcare Provider Details

I. General information

NPI: 1114749371
Provider Name (Legal Business Name): SUSANA PACHECO
Entity Type: Individual
Gender:
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/29/2024
Last Update Date: 01/13/2025
Certification Date: 01/13/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3371 PARKER HILL RD
SANTA ROSA CA
95404-1732
US

IV. Provider business mailing address

3371 PARKER HILL RD
SANTA ROSA CA
95404-1732
US

V. Phone/Fax

Practice location:
  • Phone: 707-535-0289
  • Fax:
Mailing address:
  • Phone: 707-535-0289
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code172V00000X
TaxonomyCommunity Health Worker
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: