Healthcare Provider Details

I. General information

NPI: 1598688715
Provider Name (Legal Business Name): PROVIDENCE HOLISTIC HEALING ADVANCED NURSING PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/03/2026
Last Update Date: 08/03/2026
Certification Date: 08/03/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4600 S TRACY BLVD STE 107
TRACY CA
95377-8105
US

IV. Provider business mailing address

6770 CELADON LN
TRACY CA
95377-7705
US

V. Phone/Fax

Practice location:
  • Phone: 952-261-3330
  • Fax:
Mailing address:
  • Phone: 952-261-3330
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number
License Number State

VIII. Authorized Official

Name: MAURINE B FORCHE
Title or Position: PMHNP-C
Credential:
Phone: 952-261-3330