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General NPI Number Information
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NPI Number | 1134763238
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Entity Type | Individual
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Provider Name | MARY DICOU FNP-C
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Gender | Female
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Dates
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Enumeration Date | 10/31/2019
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Last Update Date | 08/07/2020
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Provider Practice Location Address
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Address Line | 1747 N MARKET BLVD
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City | SACRAMENTO
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State | CA
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Zip | 95834-2978
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Country | US
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Telephone | 916-322-3350
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Fax |
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Provider Business Mailing Address
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Address Line | 600 BREWSTER AVE APT 101
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City | REDWOOD CITY
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State | CA
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Zip | 94063-1546
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Country | US
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Telephone | 801-234-9723
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 363LF0000X
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Taxonomy Name | Family Nurse Practitioner
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License Number | 95013137
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License Number State | CA
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