MEDICARE: MARIA THERESA LICERALDE WYSON MSN, FNP-C

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	363LF0000X	Family Nurse Practitioner	21360	CA

General Provider Information

NPI Number	:	1861769648
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MARIA THERESA LICERALDE WYSON MSN, FNP-C

Provider Business Mailing Address
First Line	:	11592 LINDAY WAY
Second Line	:
City	:	GOLD RIVER
State	:	CA
Zip	:	95670-6233
Country	:	US
Telephone Number	:	916-213-2570
Fax Number	:

Provider Business Practice Location Address
First Line	:	7811 LAGUNA BLVD STE 161
Second Line	:
City	:	ELK GROVE
State	:	CA
Zip	:	95758-7949
Country	:	US
Telephone Number	:	916-877-7778
Fax Number	:	916-896-1286

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	11/22/2011
Last Update Date	:	03/07/2023

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