Basic Information
Provider Information | |||||||||
NPI: | 1720241474 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | RIDAY | ||||||||
FirstName: | MARIBETH | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | RN, MSN, RDH | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 1400 EMELINE AVE | ||||||||
Address2: |   | ||||||||
City: | SANTA CRUZ | ||||||||
State: | CA | ||||||||
PostalCode: | 950601976 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8314544170 | ||||||||
FaxNumber: | 8314544663 | ||||||||
Practice Location | |||||||||
Address1: | 1430 FREEDOM BLVD STE B | ||||||||
Address2: |   | ||||||||
City: | WATSONVILLE | ||||||||
State: | CA | ||||||||
PostalCode: | 950762780 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8317638200 | ||||||||
FaxNumber: | 8314544663 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 07/02/2008 | ||||||||
LastUpdateDate: | 05/22/2015 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 163W00000X | 697504 | CA | N |   | Nursing Service Providers | Registered Nurse |   | 363LP0808X | 18870 | CA | Y |   | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Psych/Mental Health |
ID Information
ID | Type | State | Issuer | Description | ZZZ91891Z | 01 | CA | SANTA CRUZ COUNTY MEDICARE GROUP PTAN# | OTHER | 2012001567 | 01 | CA | ANCC B CERTIFICATION# | OTHER | ZZZ92069Z | 01 | CA | SANTA CRUZ COUNTY MEDICARE GROUP PTAN# | OTHER | 18870 | 01 | CA | NURSE PRACTITIONER FURNISHING LICENSE | OTHER | ZZZ91892Z | 01 | CA | SANTA CRUZ COUNTY MEDICARE GROUP PTAN# | OTHER | FHC40044F | 01 | CA | SANTA CRUZ COUNTY MEDICAID GROUP NUMBER | OTHER |