Healthcare Provider Details

I. General information

NPI: 1790308799
Provider Name (Legal Business Name): LISA IWANYCZKO LVN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/26/2020
Last Update Date: 05/26/2020
Certification Date: 05/26/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8946 MADISON AVE
FAIR OAKS CA
95628-4010
US

IV. Provider business mailing address

9032 HAVERING DR
ROSEVILLE CA
95747-9598
US

V. Phone/Fax

Practice location:
  • Phone: 916-438-9569
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code164X00000X
TaxonomyLicensed Vocational Nurse
License Number270176
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: