Provider Demographics
NPI:1063002756
Name:TOM, MICHELLE (NURSE PRACTITIONER)
Entity Type:Individual
Prefix:
First Name:MICHELLE
Middle Name:
Last Name:TOM
Suffix:
Gender:F
Credentials:NURSE PRACTITIONER
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7767 EL RITO WAY
Mailing Address - Street 2:
Mailing Address - City:SACRAMENTO
Mailing Address - State:CA
Mailing Address - Zip Code:95831-5411
Mailing Address - Country:US
Mailing Address - Phone:916-396-3738
Mailing Address - Fax:
Practice Address - Street 1:7767 EL RITO WAY
Practice Address - Street 2:
Practice Address - City:SACRAMENTO
Practice Address - State:CA
Practice Address - Zip Code:95831-5411
Practice Address - Country:US
Practice Address - Phone:916-396-3738
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-01-26
Last Update Date:2021-01-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA95012596363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner