=====================================================
General NPI Number Information
=====================================================
NPI Number | 1144013616
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | LISA M BANUELOS NP
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/27/2025
-----------------------------------------------------
Last Update Date | 05/27/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 100 HOSPITAL DR FL 2
-----------------------------------------------------
City | VALLEJO
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 94589-2580
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 707-427-4900
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1318 THRASHER WAY
-----------------------------------------------------
City | SUISUN CITY
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 94585-3019
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 707-246-9954
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 363LP2300X
-----------------------------------------------------
Taxonomy Name | Primary Care Nurse Practitioner
-----------------------------------------------------
License Number | 95290679
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------