Provider Demographics
NPI:1730163791
Name:HART, MARYANN (FNP)
Entity type:Individual
Prefix:MS
First Name:MARYANN
Middle Name:
Last Name:HART
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:MS
Other - First Name:MARYANN
Other - Middle Name:
Other - Last Name:HART
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:FNP
Mailing Address - Street 1:10470 OLD PLACERVILLE RD
Mailing Address - Street 2:SUITE 100
Mailing Address - City:SACRAMENTO
Mailing Address - State:CA
Mailing Address - Zip Code:95827-2539
Mailing Address - Country:US
Mailing Address - Phone:800-470-0071
Mailing Address - Fax:
Practice Address - Street 1:2751 DEL PASO RD
Practice Address - Street 2:
Practice Address - City:SACRAMENTO
Practice Address - State:CA
Practice Address - Zip Code:95835-2303
Practice Address - Country:US
Practice Address - Phone:916-453-5141
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-12-02
Last Update Date:2013-11-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA306174363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
CADM484ZMedicare PIN
CAQ59260Medicare UPIN