Basic Information
| Provider Information | |||||||||
| NPI: | 1265013023 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | ITA | ||||||||
| FirstName: | PRECIOUS MARY | ||||||||
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| Mailing Information | |||||||||
| Address1: | 461 CANYON CREEK DR | ||||||||
| Address2: | |||||||||
| City: | AMERICAN CANYON | ||||||||
| State: | CA | ||||||||
| PostalCode: | 945033938 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7076373518 | ||||||||
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| Practice Location | |||||||||
| Address1: | 2311 LOVERIDGE RD | ||||||||
| Address2: | |||||||||
| City: | PITTSBURG | ||||||||
| State: | CA | ||||||||
| PostalCode: | 945655117 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9254312600 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 04/14/2021 | ||||||||
| LastUpdateDate: | 04/14/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 04/14/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 163W00000X | 95165021 | CA | Y | Nursing Service Providers | Registered Nurse |
No ID Information.