Healthcare Provider Details

I. General information

NPI: 1104375724
Provider Name (Legal Business Name): GLORIA CRUZ
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/23/2016
Last Update Date: 01/11/2024
Certification Date: 01/11/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1212 N CALIFORNIA ST
STOCKTON CA
95202-1552
US

IV. Provider business mailing address

3502 TOWNSHEND CIR
STOCKTON CA
95212-3480
US

V. Phone/Fax

Practice location:
  • Phone: 209-953-7585
  • Fax: 209-953-7585
Mailing address:
  • Phone: 209-559-6851
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WP0809X
TaxonomyAdult Psychiatric/Mental Health Registered Nurse
License Number723203
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: