MEDICARE: ELIZABETH BARBARA WILLERUP RNP

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	363LP0808X	Psychiatric/Mental Health Nurse Practitioner	318629	CA

General Provider Information

NPI Number	:	1003801820
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	ELIZABETH BARBARA WILLERUP RNP

Provider Business Mailing Address
First Line	:	1643 EUREKA RD
Second Line	:
City	:	ROSEVILLE
State	:	CA
Zip	:	95661-3027
Country	:	US
Telephone Number	:	916-771-7627
Fax Number	:	916-771-7650

Provider Business Practice Location Address
First Line	:	1643 EUREKA RD
Second Line	:
City	:	ROSEVILLE
State	:	CA
Zip	:	95661-3027
Country	:	US
Telephone Number	:	916-771-7627
Fax Number	:	916-771-7650

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	09/19/2005
Last Update Date	:	07/08/2007

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