1386121416 NPI number — LISA LYNN RETTIG FNP

Table of content: LISA LYNN RETTIG FNP (NPI 1386121416)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1386121416 NPI number — LISA LYNN RETTIG FNP

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
RETTIG
Provider First Name:
LISA
Provider Middle Name:
LYNN
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
FNP
Provider Gender Code:
F

Provider's Other Name Information

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

NPI Number Information

NPI Number:
1386121416
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/01/2019
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 91734
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
RICHMOND
Provider Business Mailing Address State Name:
VA
Provider Business Mailing Address Postal Code:
23291-1734
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
804-358-6100
Provider Business Mailing Address Fax Number:
804-342-7619

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1000 E BROAD ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
RICHMOND
Provider Business Practice Location Address State Name:
VA
Provider Business Practice Location Address Postal Code:
23219-1930
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
804-828-2467
Provider Business Practice Location Address Fax Number:
804-827-4180
Provider Enumeration Date:
07/21/2018

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: 363LF0000X , with the licence number:  0024176382 , registered in the state of VA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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