Provider Demographics
NPI:1255429528
Name:BARACCO, MARY (CNM NP)
Entity type:Individual
Prefix:
First Name:MARY
Middle Name:
Last Name:BARACCO
Suffix:
Gender:F
Credentials:CNM NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 154
Mailing Address - Street 2:201 STEELHEAD CIRCLE
Mailing Address - City:LEWISTON
Mailing Address - State:CA
Mailing Address - Zip Code:96052-0154
Mailing Address - Country:US
Mailing Address - Phone:530-778-3354
Mailing Address - Fax:530-623-4397
Practice Address - Street 1:31 EASTER AVE
Practice Address - Street 2:
Practice Address - City:WEAVERVILLE
Practice Address - State:CA
Practice Address - Zip Code:96093-0000
Practice Address - Country:US
Practice Address - Phone:530-623-4186
Practice Address - Fax:530-623-4397
Is Sole Proprietor?:No
Enumeration Date:2006-10-11
Last Update Date:2016-09-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA490245163W00000X
CA8853363L00000X
CA1211367A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367A00000XPhysician Assistants & Advanced Practice Nursing ProvidersAdvanced Practice Midwife
No163W00000XNursing Service ProvidersRegistered Nurse
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAGR0081501OtherMEDICAL
CAGR0081500Medicaid
CAGR0081500Medicaid
CAGR0081500Medicaid