Provider Demographics
NPI:1720439730
Name:GUSENKOV, MARYANNA
Entity type:Individual
Prefix:MISS
First Name:MARYANNA
Middle Name:
Last Name:GUSENKOV
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 1:3501 JAMBOREE RD STE 1250
Mailing Address - Street 2:
Mailing Address - City:NEWPORT BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:92660-2959
Mailing Address - Country:US
Mailing Address - Phone:949-988-7800
Mailing Address - Fax:
Practice Address - Street 1:4707 42ND ST NE
Practice Address - Street 2:
Practice Address - City:TACOMA
Practice Address - State:WA
Practice Address - Zip Code:98422-2401
Practice Address - Country:US
Practice Address - Phone:253-495-0036
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-06-30
Last Update Date:2025-01-13
Deactivation Date:2024-12-31
Deactivation Code:
Reactivation Date:2025-01-09
Provider Licenses
StateLicense IDTaxonomies
CA95032261363L00000X
WA60626173376K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No376K00000XNursing Service Related ProvidersNurse's Aide