Provider Demographics
NPI:1144315730
Name:RETALLICK, ANNE C (FNP)
Entity type:Individual
Prefix:MS
First Name:ANNE
Middle Name:C
Last Name:RETALLICK
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:MS
Other - First Name:ANNE
Other - Middle Name:C
Other - Last Name:STOCK
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:RN MSN FNP
Mailing Address - Street 1:422 SOUTH BARNES STREET
Mailing Address - Street 2:
Mailing Address - City:UKIAH
Mailing Address - State:CA
Mailing Address - Zip Code:95482
Mailing Address - Country:US
Mailing Address - Phone:707-462-5861
Mailing Address - Fax:
Practice Address - Street 1:1 MADRONE ST
Practice Address - Street 2:FRANK HOWARD MEMORIAL HOSPITAL
Practice Address - City:WILLITS
Practice Address - State:CA
Practice Address - Zip Code:95490-4225
Practice Address - Country:US
Practice Address - Phone:707-459-6801
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-03
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA358288 10493163WG0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WG0000XNursing Service ProvidersRegistered NurseGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA10493OtherRN NP FURNISHING
CA10493OtherRN NP FURNISHING