Provider Demographics
NPI:1952937658
Name:SOUMAHORO, MARIAM GBATY
Entity Type:Individual
Prefix:
First Name:MARIAM
Middle Name:GBATY
Last Name:SOUMAHORO
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 1:3800 SILVER SPUR WAY
Mailing Address - Street 2:
Mailing Address - City:SACRAMENTO
Mailing Address - State:CA
Mailing Address - Zip Code:95841-4411
Mailing Address - Country:US
Mailing Address - Phone:916-904-0027
Mailing Address - Fax:
Practice Address - Street 1:3800 SILVER SPUR WAY
Practice Address - Street 2:
Practice Address - City:SACRAMENTO
Practice Address - State:CA
Practice Address - Zip Code:95841-4411
Practice Address - Country:US
Practice Address - Phone:916-904-0027
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-03-14
Last Update Date:2020-03-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA783011163WC1500X
CA342700506310400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes310400000XNursing & Custodial Care FacilitiesAssisted Living Facility
No163WC1500XNursing Service ProvidersRegistered NurseCommunity Health