Provider Demographics
NPI:1861769648
Name:WYSON, MARIA THERESA LICERALDE (MSN, FNP-C)
Entity type:Individual
Prefix:
First Name:MARIA THERESA
Middle Name:LICERALDE
Last Name:WYSON
Suffix:
Gender:F
Credentials:MSN, FNP-C
Other - Prefix:
Other - First Name:MARIA THERESA
Other - Middle Name:SIDECO
Other - Last Name:LICERALDE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:11592 LINDAY WAY
Mailing Address - Street 2:
Mailing Address - City:GOLD RIVER
Mailing Address - State:CA
Mailing Address - Zip Code:95670-6233
Mailing Address - Country:US
Mailing Address - Phone:916-213-2570
Mailing Address - Fax:
Practice Address - Street 1:7811 LAGUNA BLVD STE 161
Practice Address - Street 2:
Practice Address - City:ELK GROVE
Practice Address - State:CA
Practice Address - Zip Code:95758-7949
Practice Address - Country:US
Practice Address - Phone:916-877-7778
Practice Address - Fax:916-896-1286
Is Sole Proprietor?:Yes
Enumeration Date:2011-11-22
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA21360363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAML2654401OtherDEA