Provider Demographics
NPI:1033803408
Name:DERITA, LISA S (FNP)
Entity Type:Individual
Prefix:
First Name:LISA
Middle Name:S
Last Name:DERITA
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4549 LARIAT LN
Mailing Address - Street 2:
Mailing Address - City:OAKLEY
Mailing Address - State:CA
Mailing Address - Zip Code:94561-1718
Mailing Address - Country:US
Mailing Address - Phone:925-250-2908
Mailing Address - Fax:
Practice Address - Street 1:1280 CENTRAL BLVD STE J5
Practice Address - Street 2:
Practice Address - City:BRENTWOOD
Practice Address - State:CA
Practice Address - Zip Code:94513-2362
Practice Address - Country:US
Practice Address - Phone:925-250-2908
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-06-07
Last Update Date:2023-06-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA95025065363LP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP2300XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPrimary Care