Provider Demographics
NPI:1164987335
Name:SPONSLER, MARY (RN BSN PHN)
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:
Last Name:SPONSLER
Suffix:
Gender:F
Credentials:RN BSN PHN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:19445 SOULSBYVILLE RD
Mailing Address - Street 2:
Mailing Address - City:SOULSBYVILLE
Mailing Address - State:CA
Mailing Address - Zip Code:95372-9742
Mailing Address - Country:US
Mailing Address - Phone:209-288-8726
Mailing Address - Fax:
Practice Address - Street 1:16575 DRAPER MINE RD
Practice Address - Street 2:
Practice Address - City:SONORA
Practice Address - State:CA
Practice Address - Zip Code:95370-8430
Practice Address - Country:US
Practice Address - Phone:209-533-2300
Practice Address - Fax:209-533-4300
Is Sole Proprietor?:Yes
Enumeration Date:2019-02-01
Last Update Date:2019-02-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA481611163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes163W00000XNursing Service ProvidersRegistered NurseGroup - Multi-Specialty