Basic Information
| Provider Information | |||||||||
| NPI: | 1659434074 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | SICHERMAN | ||||||||
| FirstName: | LISA | ||||||||
| MiddleName: | S. | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | CPNP | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | GILLIAM | ||||||||
| OtherFirstName: | LISA | ||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 250 W EL MONTE WAY | ||||||||
| Address2: | |||||||||
| City: | DINUBA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 936181554 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5595959890 | ||||||||
| FaxNumber: | 5593537286 | ||||||||
| Practice Location | |||||||||
| Address1: | 9300 VALLEY CHILDRENS PL | ||||||||
| Address2: | |||||||||
| City: | MADERA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 936388761 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5593537290 | ||||||||
| FaxNumber: | 5593537286 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/18/2006 | ||||||||
| LastUpdateDate: | 11/12/2020 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 11/06/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 163W00000X | 503871 | CA | N | Nursing Service Providers | Registered Nurse | 363L00000X | 13021 | CA | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner |
ID Information
| ID | Type | State | Issuer | Description | 1659434074 | 01 | CA | NPI | OTHER |