Healthcare Provider Details

I. General information

NPI: 1629625439
Provider Name (Legal Business Name): MARISSA MAE GILGER AUD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/26/2019
Last Update Date: 10/26/2020
Certification Date: 10/26/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1761 BROADWAY ST STE 200
VALLEJO CA
94589-2227
US

IV. Provider business mailing address

457 SUTTON WAY
GRASS VALLEY CA
95945-4102
US

V. Phone/Fax

Practice location:
  • Phone: 707-645-2500
  • Fax:
Mailing address:
  • Phone: 530-477-8114
  • Fax: 530-477-1513

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code237600000X
TaxonomyAudiologist-Hearing Aid Fitter
License NumberAU3451
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: