1518063478 NPI number — MAYRE TAMARA LEE PMHNP

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1518063478 NPI number — MAYRE TAMARA LEE PMHNP

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
LEE
Provider First Name:
MAYRE
Provider Middle Name:
TAMARA
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
PMHNP
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1518063478
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
03/29/2018
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
3835 N FREEWAY BLVD STE 100
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
SACRAMENTO
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
95834-1954
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
916-576-7900
Provider Business Mailing Address Fax Number:
916-285-0338

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
770 MASON ST STE 120
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
VACAVILLE
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
95688-4648
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
707-741-3037
Provider Business Practice Location Address Fax Number:
707-451-2324
Provider Enumeration Date:
09/16/2006

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 363LP0808X , with the licence number:  10571 , registered in the state of CA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 10571 . This is a "NP LICENSE NUMBER" identifier , issued by the state of ( CA ) . This identifiers is of the category "OTHER".




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