Healthcare Provider Details

I. General information

NPI: 1033463260
Provider Name (Legal Business Name): MARY MCDONELL RD, RN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/09/2012
Last Update Date: 11/09/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

365 TESCONI CIR STE B
SANTA ROSA CA
95401-4617
US

IV. Provider business mailing address

459 RAGLE RD
SEBASTOPOL CA
95472-3131
US

V. Phone/Fax

Practice location:
  • Phone: 707-575-6043
  • Fax:
Mailing address:
  • Phone: 707-829-8718
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License Number709757
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code163WD0400X
TaxonomyDiabetes Educator Registered Nurse
License Number499778
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: