Provider Demographics
NPI:1912724550
Name:PRINCE, MARYANN (LVN)
Entity type:Individual
Prefix:
First Name:MARYANN
Middle Name:
Last Name:PRINCE
Suffix:
Gender:F
Credentials:LVN
Other - Prefix:
Other - First Name:MARYANN
Other - Middle Name:
Other - Last Name:WHITE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:8974 FAIRWAY DR
Mailing Address - Street 2:
Mailing Address - City:KELSEYVILLE
Mailing Address - State:CA
Mailing Address - Zip Code:95451-9561
Mailing Address - Country:US
Mailing Address - Phone:707-791-6882
Mailing Address - Fax:
Practice Address - Street 1:1202 APOLLO WAY
Practice Address - Street 2:
Practice Address - City:SANTA ROSA
Practice Address - State:CA
Practice Address - Zip Code:95407-6777
Practice Address - Country:US
Practice Address - Phone:707-565-4300
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-09-24
Last Update Date:2024-09-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA275588164X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164X00000XNursing Service ProvidersLicensed Vocational Nurse