1295750917 NPI number — LISA B DAVIS CRNA

Table of content: LISA B DAVIS CRNA (NPI 1295750917)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1295750917 NPI number — LISA B DAVIS CRNA

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
DAVIS
Provider First Name:
LISA
Provider Middle Name:
B
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
CRNA
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
BRUNO
Provider Other First Name:
LISA
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
CRNA
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1295750917
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
11/08/2011
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
4901 GRANDE DR
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
PENSACOLA
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
32504-5935
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
850-477-7042
Provider Business Mailing Address Fax Number:
850-474-9060

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
4901 GRANDE DR
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
PENSACOLA
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
32504-5935
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
850-477-7042
Provider Business Practice Location Address Fax Number:
850-474-9060
Provider Enumeration Date:
07/13/2006

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 367500000X , with the licence number:  ARNP2548242 , registered in the state of FL ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 430041999 . This is a "MEDICARE RAILROAD" identifier , issued by the state of ( FL ) . This identifiers is of the category "OTHER".
  • Identifier: 591-59917 . This is a "BLUE CROSS BLUE SHIELD" identifier , issued by the state of ( AL ) . This identifiers is of the category "OTHER".
  • Identifier: 303622700 , issued by the state of ( FL ) . This identifiers is of the category "MEDICAID".
  • Identifier: 009953960 , issued by the state of ( AL ) . This identifiers is of the category "MEDICAID".
  • Identifier: G2148 . This is a "BLUE CROSS & BLUE SHIELD" identifier , issued by the state of ( FL ) . This identifiers is of the category "OTHER".




Copyright © 2007-2024 www.npivalidator.com