MEDICARE: CARLA RAE OBRIEN-JAY

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	163W00000X	Registered Nurse	528802	CA

General Provider Information

NPI Number	:	1588932107
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	CARLA RAE OBRIEN-JAY

Provider Business Mailing Address
First Line	:	202 PLEASANT HILL AVE N
Second Line	:
City	:	SEBASTOPOL
State	:	CA
Zip	:	95472-3106
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	7425 RANCHO LOS GUILICOS RD
Second Line	:
City	:	SANTA ROSA
State	:	CA
Zip	:	95409-6519
Country	:	US
Telephone Number	:	707-565-6344
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	12/09/2011
Last Update Date	:	12/09/2011

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