Basic Information
| Provider Information | |||||||||
| NPI: | 1972683753 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MORTENSEN | ||||||||
| FirstName: | THERESA | ||||||||
| MiddleName: | LOUISE | ||||||||
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| Credential: | N.P. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3555 ROUND BARN CIR | ||||||||
| Address2: | |||||||||
| City: | SANTA ROSA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 954031757 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7075281050 | ||||||||
| FaxNumber: | 7075253874 | ||||||||
| Practice Location | |||||||||
| Address1: | 3555 ROUND BARN CIR | ||||||||
| Address2: | |||||||||
| City: | SANTA ROSA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 954031757 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7075281050 | ||||||||
| FaxNumber: | 7075253874 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/16/2006 | ||||||||
| LastUpdateDate: | 11/08/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 11/08/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363L00000X | 402482 | CA | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner |
ID Information
| ID | Type | State | Issuer | Description | RN402482 | 05 | CA | MEDICAID |