Provider Demographics
NPI:1093914517
Name:BURGESS, LISA DAWN (LPN)
Entity Type:Individual
Prefix:MRS
First Name:LISA
Middle Name:DAWN
Last Name:BURGESS
Suffix:
Gender:F
Credentials:LPN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:136 MAPLE ST
Mailing Address - Street 2:
Mailing Address - City:ASHLAND
Mailing Address - State:OH
Mailing Address - Zip Code:44805-3264
Mailing Address - Country:US
Mailing Address - Phone:419-496-2052
Mailing Address - Fax:
Practice Address - Street 1:136 MAPLE ST
Practice Address - Street 2:
Practice Address - City:ASHLAND
Practice Address - State:OH
Practice Address - Zip Code:44805-3264
Practice Address - Country:US
Practice Address - Phone:419-496-2052
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-07-14
Last Update Date:2007-07-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHPN112553164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse