Healthcare Provider Details

I. General information

NPI: 1023607348
Provider Name (Legal Business Name): LISA HERSAM RN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/12/2021
Last Update Date: 01/12/2021
Certification Date: 01/12/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2279 45TH ST
SACRAMENTO CA
95817-1514
US

IV. Provider business mailing address

991 MOONLIT WAY
FOLSOM CA
95630-7506
US

V. Phone/Fax

Practice location:
  • Phone: 916-734-5959
  • Fax:
Mailing address:
  • Phone: 916-734-5959
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WP0218X
TaxonomyPediatric Oncology Registered Nurse
License Number557147
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: