Provider Demographics
NPI:1700079175
Name:TRUMBULL, ERICA ILANA (LAC)
Entity Type:Individual
Prefix:MS
First Name:ERICA
Middle Name:ILANA
Last Name:TRUMBULL
Suffix:
Gender:F
Credentials:LAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:497 CORTE MADERA AVE
Mailing Address - Street 2:
Mailing Address - City:CORTE MADERA
Mailing Address - State:CA
Mailing Address - Zip Code:94925-1310
Mailing Address - Country:US
Mailing Address - Phone:510-501-3813
Mailing Address - Fax:
Practice Address - Street 1:45 SAN CLEMENTE DR STE D130
Practice Address - Street 2:
Practice Address - City:CORTE MADERA
Practice Address - State:CA
Practice Address - Zip Code:94925-1254
Practice Address - Country:US
Practice Address - Phone:510-501-3813
Practice Address - Fax:415-891-3991
Is Sole Proprietor?:Yes
Enumeration Date:2007-08-20
Last Update Date:2021-01-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
171100000X
CAAC 7862171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist