Provider Demographics
NPI:1962487710
Name:OSBORN, MARY KAY (FNP)
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:KAY
Last Name:OSBORN
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:
Other - First Name:MARY
Other - Middle Name:KAY
Other - Last Name:WEBB
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1095 MARSHALL WAY
Mailing Address - Street 2:
Mailing Address - City:PLACERVILLE
Mailing Address - State:CA
Mailing Address - Zip Code:95667-6533
Mailing Address - Country:US
Mailing Address - Phone:530-626-2920
Mailing Address - Fax:530-626-2974
Practice Address - Street 1:1095 MARSHALL WAY
Practice Address - Street 2:
Practice Address - City:PLACERVILLE
Practice Address - State:CA
Practice Address - Zip Code:95667-5722
Practice Address - Country:US
Practice Address - Phone:530-626-2920
Practice Address - Fax:530-626-2974
Is Sole Proprietor?:No
Enumeration Date:2005-12-14
Last Update Date:2007-07-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CARN319014163W00000X
CANP4926363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No163W00000XNursing Service ProvidersRegistered Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
S54517Medicare UPIN