Healthcare Provider Details

I. General information

NPI: 1568076883
Provider Name (Legal Business Name): HEATHER A TUCKER-BJORUM
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/03/2020
Last Update Date: 08/02/2022
Certification Date: 08/02/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10535 HOSPITAL WAY
MATHER CA
95655-4200
US

IV. Provider business mailing address

2220 10TH ST APT 1/2
SACRAMENTO CA
95818-1316
US

V. Phone/Fax

Practice location:
  • Phone: 916-366-5406
  • Fax:
Mailing address:
  • Phone: 775-230-0438
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number95016783
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number833735
License Number StateNV

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: