Healthcare Provider Details

I. General information

NPI: 1467686543
Provider Name (Legal Business Name): MARY ISSITT IDMT
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: MARY CRUZ

II. Dates (important events)

Enumeration Date: 05/05/2009
Last Update Date: 04/03/2020
Certification Date: 04/03/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

DAVID GRANT MEDICAL CENTER 101 BODIN CIRCLE
TRAVIS AFB CA
94535-0001
US

IV. Provider business mailing address

5344 ANTHONY CT
FAIRFIELD CA
94533-1581
US

V. Phone/Fax

Practice location:
  • Phone: 707-816-5950
  • Fax:
Mailing address:
  • Phone: 501-615-5633
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1710I1003X
TaxonomyIndependent Duty Medical Technicians
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: