Healthcare Provider Details

I. General information

NPI: 1063963221
Provider Name (Legal Business Name): LIZYKUTTY THOMAS
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/21/2016
Last Update Date: 12/09/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5674 STONERIDGE DR
PLEASANTON CA
94588-8500
US

IV. Provider business mailing address

5674 STONERIDGE DR
PLEASANTON CA
94588-8500
US

V. Phone/Fax

Practice location:
  • Phone: 925-520-0005
  • Fax: 925-892-9820
Mailing address:
  • Phone: 925-520-0005
  • Fax: 925-892-9820

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number614721
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: