1265837363 NPI number — LISA MARIE ANSELL ED. D.

Table of content: LISA MARIE ANSELL ED. D. (NPI 1265837363)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1265837363 NPI number — LISA MARIE ANSELL ED. D.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
ANSELL
Provider First Name:
LISA
Provider Middle Name:
MARIE
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
ED. D.
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
CORNWELL
Provider Other First Name:
LISA
Provider Other Middle Name:
MARIE
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:
1265837363
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
09/28/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 1845
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
GRANDBY
Provider Business Mailing Address State Name:
CO
Provider Business Mailing Address Postal Code:
80446-1845
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
970-509-0321
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
195 N. 3RD STREET
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
GRANBY
Provider Business Practice Location Address State Name:
CO
Provider Business Practice Location Address Postal Code:
80446
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
970-509-0321
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
10/31/2014

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: 101Y00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 101YM0800X , with the licence number: LPC.0014645 , registered in the state of CO ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 9000184658 , issued by the state of ( CO ) . This identifiers is of the category "MEDICAID".




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