Healthcare Provider Details

I. General information

NPI: 1437768082
Provider Name (Legal Business Name): MARITZA SAUCEDO ROSAS PMHNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/29/2020
Last Update Date: 12/05/2022
Certification Date: 12/05/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2235 CHALLENGER WAY STE 101
SANTA ROSA CA
95407-5421
US

IV. Provider business mailing address

1129 GUMWOOD LN
PETALUMA CA
94954-4330
US

V. Phone/Fax

Practice location:
  • Phone: 707-565-4900
  • Fax:
Mailing address:
  • Phone: 415-497-3501
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number95018455
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number StateNULL
# 3
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number95202174
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: