Healthcare Provider Details

I. General information

NPI: 1962948372
Provider Name (Legal Business Name): MS. ELYSE LAUREN BYRUM
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/09/2017
Last Update Date: 01/09/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

212 I ST
DAVIS CA
95616-4213
US

IV. Provider business mailing address

212 I ST
DAVIS CA
95616-4213
US

V. Phone/Fax

Practice location:
  • Phone: 530-601-5959
  • Fax: 916-287-4679
Mailing address:
  • Phone: 530-601-5959
  • Fax: 916-287-4679

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code174400000X
TaxonomySpecialist
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: