Healthcare Provider Details

I. General information

NPI: 1134867260
Provider Name (Legal Business Name): LYNN TABB NOYCE NURSE PRACTITIONER
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/27/2022
Last Update Date: 10/14/2022
Certification Date: 10/14/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1144 65TH ST STE F
OAKLAND CA
94608-1053
US

IV. Provider business mailing address

1144 65TH ST STE F
OAKLAND CA
94608-1053
US

V. Phone/Fax

Practice location:
  • Phone: 510-929-1400
  • Fax: 510-929-1414
Mailing address:
  • Phone: 510-929-1400
  • Fax: 510-929-1414

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LG0600X
TaxonomyGerontology Nurse Practitioner
License Number95019519
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: