Healthcare Provider Details

I. General information

NPI: 1861769648
Provider Name (Legal Business Name): MARIA THERESA LICERALDE WYSON MSN, FNP-C
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: MARIA THERESA SIDECO LICERALDE

II. Dates (important events)

Enumeration Date: 11/22/2011
Last Update Date: 03/07/2023
Certification Date: 10/01/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7811 LAGUNA BLVD STE 161
ELK GROVE CA
95758-7949
US

IV. Provider business mailing address

11592 LINDAY WAY
GOLD RIVER CA
95670-6233
US

V. Phone/Fax

Practice location:
  • Phone: 916-877-7778
  • Fax: 916-896-1286
Mailing address:
  • Phone: 916-213-2570
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number21360
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: