Basic Information
Provider Information | |||||||||
NPI: | 1326467804 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | SEBASTIAN | ||||||||
FirstName: | ANNE | ||||||||
MiddleName: | NELSON | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | NP | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: | BROTHERTON | ||||||||
OtherFirstName: | ANNE | ||||||||
OtherMiddleName: | NELSON | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: | NP | ||||||||
OtherLastNameType: | 1 | ||||||||
Mailing Information | |||||||||
Address1: | 1179 N MCDOWELL BLVD | ||||||||
Address2: |   | ||||||||
City: | PETALUMA | ||||||||
State: | CA | ||||||||
PostalCode: | 949546559 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 7075597500 | ||||||||
FaxNumber: | 7075597620 | ||||||||
Practice Location | |||||||||
Address1: | 1179 N MCDOWELL BLVD | ||||||||
Address2: |   | ||||||||
City: | PETALUMA | ||||||||
State: | CA | ||||||||
PostalCode: | 949546559 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 7075597500 | ||||||||
FaxNumber: | 7075597620 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 04/10/2014 | ||||||||
LastUpdateDate: | 01/26/2022 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 01/26/2022 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LF0000X | 95000355 | CA | Y |   | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family |
No ID Information.