Provider Demographics
NPI:1992036339
Name:KOPPERUD, LINDSEY DIANE (NP,PHN, BSN, ANP-BC)
Entity Type:Individual
Prefix:
First Name:LINDSEY
Middle Name:DIANE
Last Name:KOPPERUD
Suffix:
Gender:F
Credentials:NP,PHN, BSN, ANP-BC
Other - Prefix:
Other - First Name:LINDSEY
Other - Middle Name:
Other - Last Name:MEADOWS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:4805 POLO CT
Mailing Address - Street 2:
Mailing Address - City:FAIR OAKS
Mailing Address - State:CA
Mailing Address - Zip Code:95628-5266
Mailing Address - Country:US
Mailing Address - Phone:530-521-7740
Mailing Address - Fax:
Practice Address - Street 1:2315 STOCKTON BLVD
Practice Address - Street 2:
Practice Address - City:SACRAMENTO
Practice Address - State:CA
Practice Address - Zip Code:95817-2201
Practice Address - Country:US
Practice Address - Phone:916-734-2011
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-01-25
Last Update Date:2021-01-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA10898363L00000X
CA653636363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA653636OtherREGISTERED NURSE LICENSURE
CA20898OtherCERTIFIED ADULT NURSE PRACTITIONER
CA3634OtherCERTIFIED CLINICAL NURSE SPECIALIST