Healthcare Provider Details

I. General information

NPI: 1710013024
Provider Name (Legal Business Name): MARIELA BADUM RN, BSN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: MARIELA BADUM PHN

II. Dates (important events)

Enumeration Date: 02/23/2007
Last Update Date: 12/01/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

327 COLLEGE AVE.
SANTA ROSA CA
95401-5117
US

IV. Provider business mailing address

327 COLLEGE AVE.
SANTA ROSA CA
95401-5117
US

V. Phone/Fax

Practice location:
  • Phone: 707-568-2800
  • Fax: 707-568-2804
Mailing address:
  • Phone: 707-568-2800
  • Fax: 707-568-2804

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code164X00000X
TaxonomyLicensed Vocational Nurse
License NumberLVN216445
License Number StateCA
# 2
Primary TaxonomyY
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number723539
License Number StateCA
# 3
Primary TaxonomyN
Taxonomy Code163WC1500X
TaxonomyCommunity Health Registered Nurse
License Number73297
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: