Provider Demographics
NPI:1194208462
Name:STAUFFER, LISA ANN (CPHT)
Entity Type:Individual
Prefix:
First Name:LISA
Middle Name:ANN
Last Name:STAUFFER
Suffix:
Gender:F
Credentials:CPHT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2102 NEZ PERCE DR
Mailing Address - Street 2:
Mailing Address - City:LEWISTON
Mailing Address - State:ID
Mailing Address - Zip Code:83501-4116
Mailing Address - Country:US
Mailing Address - Phone:208-743-4434
Mailing Address - Fax:208-743-9422
Practice Address - Street 1:2102 NEZ PERCE DR
Practice Address - Street 2:
Practice Address - City:LEWISTON
Practice Address - State:ID
Practice Address - Zip Code:83501-4116
Practice Address - Country:US
Practice Address - Phone:208-743-4434
Practice Address - Fax:208-743-9422
Is Sole Proprietor?:No
Enumeration Date:2018-09-12
Last Update Date:2018-09-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ID1225043342183700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183700000XPharmacy Service ProvidersPharmacy Technician
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID1225043342Medicaid