Provider Demographics
NPI:1457010266
Name:BAUM, JODI (LVN)
Entity Type:Individual
Prefix:
First Name:JODI
Middle Name:
Last Name:BAUM
Suffix:
Gender:F
Credentials:LVN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 1601
Mailing Address - Street 2:
Mailing Address - City:BODEGA BAY
Mailing Address - State:CA
Mailing Address - Zip Code:94923-1601
Mailing Address - Country:US
Mailing Address - Phone:707-483-9642
Mailing Address - Fax:
Practice Address - Street 1:1280 SUMMERFIELD RD
Practice Address - Street 2:
Practice Address - City:SANTA ROSA
Practice Address - State:CA
Practice Address - Zip Code:95405-7313
Practice Address - Country:US
Practice Address - Phone:707-483-9642
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-12-09
Last Update Date:2021-12-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA222700164X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164X00000XNursing Service ProvidersLicensed Vocational Nurse