Provider Demographics
NPI:1790725075
Name:HOWELL, MARY WALLACE (PAC FNP)
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:WALLACE
Last Name:HOWELL
Suffix:
Gender:F
Credentials:PAC FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:632 W GIBSON RD
Mailing Address - Street 2:
Mailing Address - City:WOODLAND
Mailing Address - State:CA
Mailing Address - Zip Code:95695-5169
Mailing Address - Country:US
Mailing Address - Phone:530-666-1631
Mailing Address - Fax:
Practice Address - Street 1:2330 W COVELL BLVD STE 100
Practice Address - Street 2:
Practice Address - City:DAVIS
Practice Address - State:CA
Practice Address - Zip Code:95616
Practice Address - Country:US
Practice Address - Phone:530-668-2660
Practice Address - Fax:530-756-5817
Is Sole Proprietor?:No
Enumeration Date:2006-06-07
Last Update Date:2018-06-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CANP8902363L00000X
CAPA14001363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAPA14001OtherMEDI-CAL
CAPA14001OtherMEDI-CAL
CAS67814Medicare UPIN