Provider Demographics
NPI:1417427014
Name:NIETO, MARISA GABRIELLE
Entity Type:Individual
Prefix:
First Name:MARISA
Middle Name:GABRIELLE
Last Name:NIETO
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 1:7949 CALIFORNIA AVE STE 15
Mailing Address - Street 2:
Mailing Address - City:FAIR OAKS
Mailing Address - State:CA
Mailing Address - Zip Code:95628-7156
Mailing Address - Country:US
Mailing Address - Phone:916-863-7949
Mailing Address - Fax:
Practice Address - Street 1:601 COURT ST STE 100
Practice Address - Street 2:
Practice Address - City:JACKSON
Practice Address - State:CA
Practice Address - Zip Code:95642-2162
Practice Address - Country:US
Practice Address - Phone:209-257-1244
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-11-27
Last Update Date:2023-09-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA171M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes171M00000XOther Service ProvidersCase Manager/Care CoordinatorGroup - Single Specialty