MEDICARE: LICHELLE NUCUM LUM N.P.

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	363LF0000X	Family Nurse Practitioner	95000924	CA

General Provider Information

NPI Number	:	1588071179
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	LICHELLE NUCUM LUM N.P.

Provider Business Mailing Address
First Line	:	100 HOSPITAL DR STE 110
Second Line	:
City	:	VALLEJO
State	:	CA
Zip	:	94589-2577
Country	:	US
Telephone Number	:	707-551-3300
Fax Number	:	707-551-3301

Provider Business Practice Location Address
First Line	:	100 HOSPITAL DR STE 110
Second Line	:
City	:	VALLEJO
State	:	CA
Zip	:	94589-2577
Country	:	US
Telephone Number	:	707-551-3300
Fax Number	:	707-551-3301

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

Provider Enumeration Date	:	07/16/2014
Last Update Date	:	10/22/2014

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