MEDICARE: CHERRY SHERLYN ELMORE FNP

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	163WC0400X	Case Management Registered Nurse	548255	CA
2	163WC1500X	Community Health Registered Nurse	548255	CA
3	163WM0102X	Maternal Newborn Registered Nurse	548255	CA
4	363L00000X	Nurse Practitioner	20744	CA

Medicare Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	GR157Z	OTHER	CA	MEDICARE PTAN

General Provider Information

NPI Number	:	1780748640
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	CHERRY SHERLYN ELMORE FNP

Provider Business Mailing Address
First Line	:	1691 THE ALAMEDA
Second Line	:
City	:	SAN JOSE
State	:	CA
Zip	:	95126-2203
Country	:	US
Telephone Number	:	408-795-3600
Fax Number	:	408-287-0405

Provider Business Practice Location Address
First Line	:	5385 FRANKLIN BLVD
Second Line	:
City	:	SACRAMENTO
State	:	CA
Zip	:	95820-4717
Country	:	US
Telephone Number	:	916-452-7305
Fax Number	:	916-452-9753

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

Provider Enumeration Date	:	12/21/2006
Last Update Date	:	11/15/2012

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