Provider Demographics
NPI:1225598972
Name:JUSTUS, LISA MAE (REGISTERED NURSE)
Entity Type:Individual
Prefix:
First Name:LISA
Middle Name:MAE
Last Name:JUSTUS
Suffix:
Gender:F
Credentials:REGISTERED NURSE
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:36237 WESTFIELD DR
Mailing Address - Street 2:
Mailing Address - City:NORTH RIDGEVILLE
Mailing Address - State:OH
Mailing Address - Zip Code:44039-3839
Mailing Address - Country:US
Mailing Address - Phone:440-865-4804
Mailing Address - Fax:
Practice Address - Street 1:41641 N RIDGE RD
Practice Address - Street 2:
Practice Address - City:ELYRIA
Practice Address - State:OH
Practice Address - Zip Code:44035-1264
Practice Address - Country:US
Practice Address - Phone:440-324-7406
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-03-20
Last Update Date:2019-03-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHRN.447510163WP0808X, 163WA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WA0400XNursing Service ProvidersRegistered NurseAddiction (Substance Use Disorder)
No163WP0808XNursing Service ProvidersRegistered NursePsychiatric/Mental Health