Provider Demographics
NPI:1760835813
Name:MAYBERRY, SUSAN
Entity Type:Individual
Prefix:
First Name:SUSAN
Middle Name:
Last Name:MAYBERRY
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 1:230 JASMINE ST
Mailing Address - Street 2:
Mailing Address - City:FAIRFIELD
Mailing Address - State:CA
Mailing Address - Zip Code:94533-1527
Mailing Address - Country:US
Mailing Address - Phone:707-803-5784
Mailing Address - Fax:
Practice Address - Street 1:230 JASMINE ST
Practice Address - Street 2:
Practice Address - City:FAIRFIELD
Practice Address - State:CA
Practice Address - Zip Code:94533-1527
Practice Address - Country:US
Practice Address - Phone:707-803-5784
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-07-13
Last Update Date:2016-07-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA420093163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse