Healthcare Provider Details

I. General information

NPI: 1033262654
Provider Name (Legal Business Name): LUCILLE A CAPO ROME NP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/18/2007
Last Update Date: 04/11/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2225 CHALLENGER WAY
SANTA ROSA CA
95407-5441
US

IV. Provider business mailing address

2225 CHALLENGER WAY
SANTA ROSA CA
95407-5441
US

V. Phone/Fax

Practice location:
  • Phone: 707-565-6625
  • Fax:
Mailing address:
  • Phone: 707-565-6625
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WP0809X
TaxonomyAdult Psychiatric/Mental Health Registered Nurse
License Number497364
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number6863
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: