Provider Demographics
NPI:1407068059
Name:SHELTON-GROSS, MARJORIE
Entity Type:Individual
Prefix:
First Name:MARJORIE
Middle Name:
Last Name:SHELTON-GROSS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1442 ETHAN WAY
Mailing Address - Street 2:SUITE 200
Mailing Address - City:SACRAMENTO
Mailing Address - State:CA
Mailing Address - Zip Code:95825-2231
Mailing Address - Country:US
Mailing Address - Phone:916-481-8600
Mailing Address - Fax:916-481-9636
Practice Address - Street 1:1469 HUMBOLDT RD
Practice Address - Street 2:SUITE 200
Practice Address - City:CHICO
Practice Address - State:CA
Practice Address - Zip Code:95928-9116
Practice Address - Country:US
Practice Address - Phone:530-891-1917
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-05-04
Last Update Date:2014-12-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG455730207VH0002X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207VH0002XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyHospice and Palliative Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CACMM70268FMedicaid
CACMM70370FMedicaid
CACMM70116GMedicaid
CAZZR11629FMedicaid