Provider Demographics
NPI:1982811824
Name:RUIZ, SAMMIE SHELTON (LVN)
Entity Type:Individual
Prefix:
First Name:SAMMIE
Middle Name:SHELTON
Last Name:RUIZ
Suffix:
Gender:F
Credentials:LVN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4165 W PRINCETON AVE
Mailing Address - Street 2:
Mailing Address - City:FRESNO
Mailing Address - State:CA
Mailing Address - Zip Code:93722-6804
Mailing Address - Country:US
Mailing Address - Phone:559-276-7046
Mailing Address - Fax:
Practice Address - Street 1:2780 W ADAMS AVE
Practice Address - Street 2:
Practice Address - City:FRESNO
Practice Address - State:CA
Practice Address - Zip Code:93706-9601
Practice Address - Country:US
Practice Address - Phone:559-264-6046
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-17
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAVN199363164X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164X00000XNursing Service ProvidersLicensed Vocational Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
CARVN003930Medicaid