Provider Demographics
NPI:1033262654
Name:CAPO ROME, LUCILLE A (NP)
Entity Type:Individual
Prefix:MRS
First Name:LUCILLE
Middle Name:A
Last Name:CAPO ROME
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2225 CHALLENGER WAY
Mailing Address - Street 2:
Mailing Address - City:SANTA ROSA
Mailing Address - State:CA
Mailing Address - Zip Code:95407-5441
Mailing Address - Country:US
Mailing Address - Phone:707-565-6625
Mailing Address - Fax:
Practice Address - Street 1:2225 CHALLENGER WAY
Practice Address - Street 2:
Practice Address - City:SANTA ROSA
Practice Address - State:CA
Practice Address - Zip Code:95407-5441
Practice Address - Country:US
Practice Address - Phone:707-565-6625
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-01-18
Last Update Date:2017-04-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA497364163WP0809X
CA6863363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WP0809XNursing Service ProvidersRegistered NursePsychiatric/Mental Health, Adult
No363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO807779Medicare UPIN