Provider Demographics
NPI:1558656215
Name:HUMPHREYS, MARY ELIZABETH (RN, BSN, PHN)
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:ELIZABETH
Last Name:HUMPHREYS
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 1:1100 ROSEVILLE PKWY
Mailing Address - Street 2:#921
Mailing Address - City:ROSEVILLE
Mailing Address - State:CA
Mailing Address - Zip Code:95678-4100
Mailing Address - Country:US
Mailing Address - Phone:707-718-6018
Mailing Address - Fax:
Practice Address - Street 1:5730 PACKARD AVE
Practice Address - Street 2:#100
Practice Address - City:MARYSVILLE
Practice Address - State:CA
Practice Address - Zip Code:95901-7118
Practice Address - Country:US
Practice Address - Phone:530-749-6492
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-06-10
Last Update Date:2011-06-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA791218163WC0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WC0400XNursing Service ProvidersRegistered NurseCase Management