Provider Demographics
NPI:1770058521
Name:GRUSSENMEYER, TRACI JANE
Entity type:Individual
Prefix:
First Name:TRACI
Middle Name:JANE
Last Name:GRUSSENMEYER
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 1:3159 BERTIS DR
Mailing Address - Street 2:
Mailing Address - City:SACRAMENTO
Mailing Address - State:CA
Mailing Address - Zip Code:95821-4453
Mailing Address - Country:US
Mailing Address - Phone:480-250-9156
Mailing Address - Fax:
Practice Address - Street 1:9300 VALLEY CHILDRENS PL # SC05
Practice Address - Street 2:
Practice Address - City:MADERA
Practice Address - State:CA
Practice Address - Zip Code:93636-8761
Practice Address - Country:US
Practice Address - Phone:559-353-5700
Practice Address - Fax:559-353-5708
Is Sole Proprietor?:No
Enumeration Date:2018-10-08
Last Update Date:2020-10-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA95010232363LF0000X
CA56099363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily