Basic Information
| Provider Information | |||||||||
| NPI: | 1609050681 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | COVERDELL | ||||||||
| FirstName: | MARY | ||||||||
| MiddleName: | ANN | ||||||||
| NamePrefix: | MS. | ||||||||
| NameSuffix: | |||||||||
| Credential: | RN APN | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3400 DATA DR | ||||||||
| Address2: | |||||||||
| City: | RANCHO CORDOVA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 956707956 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9163792726 | ||||||||
| FaxNumber: | 9168537874 | ||||||||
| Practice Location | |||||||||
| Address1: | 7115 GREENBACK LN | ||||||||
| Address2: | FL 2 | ||||||||
| City: | CITRUS HEIGHTS | ||||||||
| State: | CA | ||||||||
| PostalCode: | 956216133 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9165363620 | ||||||||
| FaxNumber: | 9165363541 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/26/2007 | ||||||||
| LastUpdateDate: | 03/16/2020 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 03/16/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LF0000X | 18626 | CA | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family |
ID Information
| ID | Type | State | Issuer | Description | 160905681 | 05 | CA | MEDICAID |