=====================================================
General NPI Number Information
=====================================================
NPI Number | 1235696964
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | LUKE CODY ROY FNP-BC
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/28/2019
-----------------------------------------------------
Last Update Date | 03/04/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 5555 GROSSMONT CENTER DR
-----------------------------------------------------
City | LA MESA
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 91942-3019
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 619-740-3058
-----------------------------------------------------
Fax | 619-740-3967
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 4320 MAYAPAN DR
-----------------------------------------------------
City | LA MESA
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 91941-7142
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 619-335-6799
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 163W00000X
-----------------------------------------------------
Taxonomy Name | Registered Nurse
-----------------------------------------------------
License Number | 786655
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 163WE0003X
-----------------------------------------------------
Taxonomy Name | Emergency Registered Nurse
-----------------------------------------------------
License Number | B01084732
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------
Taxonomy #3
-----------------------------------------------------
Taxonomy Code | 363LF0000X
-----------------------------------------------------
Taxonomy Name | Family Nurse Practitioner
-----------------------------------------------------
License Number | NP95011115
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------