Healthcare Provider Details

I. General information

NPI: 1437497948
Provider Name (Legal Business Name): JERVIA ISHUM SIMON FICKENS ANP
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/18/2013
Last Update Date: 01/18/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

NAVAL HOSPITAL LEMOORE 937 FRANKLIN AVE
LEMOORE CA
93246-5004
US

IV. Provider business mailing address

NAVAL HOSPITAL LEMOORE 937 FRANKLIN AVE
LEMOORE CA
93246-5004
US

V. Phone/Fax

Practice location:
  • Phone: 559-998-4208
  • Fax:
Mailing address:
  • Phone: 559-998-4208
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LA2200X
TaxonomyAdult Health Nurse Practitioner
License Number22451
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: