Basic Information
| Provider Information | |||||||||
| NPI: | 1194744748 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | SNELGROVE | ||||||||
| FirstName: | MARY | ||||||||
| MiddleName: | DODICH | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | FNP-C, MSN | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | DODICH | ||||||||
| OtherFirstName: | MARY | ||||||||
| OtherMiddleName: | M | ||||||||
| OtherNamePrefix: | |||||||||
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| OtherCredential: | |||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 2767 OLIVE HWY | ||||||||
| Address2: | |||||||||
| City: | OROVILLE | ||||||||
| State: | CA | ||||||||
| PostalCode: | 959666118 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5305328584 | ||||||||
| FaxNumber: | 5305328272 | ||||||||
| Practice Location | |||||||||
| Address1: | 2767 OLIVE HWY | ||||||||
| Address2: | |||||||||
| City: | OROVILLE | ||||||||
| State: | CA | ||||||||
| PostalCode: | 959666118 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5305328584 | ||||||||
| FaxNumber: | 5305328272 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/18/2006 | ||||||||
| LastUpdateDate: | 04/02/2014 | ||||||||
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| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
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| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363L00000X | 11984NP | CA | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner |
ID Information
| ID | Type | State | Issuer | Description | ZZZ15808Z | 05 | CA | MEDICAID |