Provider Demographics
NPI:1578121224
Name:VANGUILDER, MARISSA (CRNA)
Entity Type:Individual
Prefix:
First Name:MARISSA
Middle Name:
Last Name:VANGUILDER
Suffix:
Gender:F
Credentials:CRNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2602 ALLEGIANCE LN
Mailing Address - Street 2:
Mailing Address - City:RIVERBANK
Mailing Address - State:CA
Mailing Address - Zip Code:95367-9402
Mailing Address - Country:US
Mailing Address - Phone:209-404-5776
Mailing Address - Fax:
Practice Address - Street 1:2615 CHESTER AVE
Practice Address - Street 2:
Practice Address - City:BAKERSFIELD
Practice Address - State:CA
Practice Address - Zip Code:93301-2014
Practice Address - Country:US
Practice Address - Phone:661-395-3000
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-05-29
Last Update Date:2019-09-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA728685163W00000X
CA95001184367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
No163W00000XNursing Service ProvidersRegistered Nurse