Healthcare Provider Details

I. General information

NPI: 1053921064
Provider Name (Legal Business Name): JESSICA STANKIEWICZ LIGHTCAP MSN, RN, ACCNS-P
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/04/2020
Last Update Date: 08/04/2020
Certification Date: 08/04/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

747 52ND ST
OAKLAND CA
94609-1809
US

IV. Provider business mailing address

747 52ND ST
OAKLAND CA
94609-1809
US

V. Phone/Fax

Practice location:
  • Phone: 510-428-3885
  • Fax: 510-597-7194
Mailing address:
  • Phone: 510-428-3885
  • Fax: 510-597-7194

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code364SP0200X
TaxonomyPediatric Clinical Nurse Specialist
License NumberCNS4808
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License NumberRN810614
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: