Provider Demographics
NPI:1801447230
Name:MACISAAC, PATTY
Entity type:Individual
Prefix:
First Name:PATTY
Middle Name:
Last Name:MACISAAC
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 1:3221 OAK FARM LANE
Mailing Address - Street 2:
Mailing Address - City:SANTA ROSA
Mailing Address - State:CA
Mailing Address - Zip Code:95401
Mailing Address - Country:US
Mailing Address - Phone:530-949-5717
Mailing Address - Fax:
Practice Address - Street 1:3221 OAK FARM LANE
Practice Address - Street 2:
Practice Address - City:SANTA ROSA
Practice Address - State:CA
Practice Address - Zip Code:95401
Practice Address - Country:US
Practice Address - Phone:530-949-5717
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-09-26
Last Update Date:2019-09-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
3747A0650X
CA3747A0650X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3747A0650XNursing Service Related ProvidersTechnicianAttendant Care Provider