Provider Demographics
NPI:1235190778
Name:DANIEL, LISA ANN (CRNA)
Entity Type:Individual
Prefix:
First Name:LISA
Middle Name:ANN
Last Name:DANIEL
Suffix:
Gender:F
Credentials:CRNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2080 W ARLINGTON BLVD
Mailing Address - Street 2:SUITE B
Mailing Address - City:GREENVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:27834-3770
Mailing Address - Country:US
Mailing Address - Phone:252-752-2140
Mailing Address - Fax:
Practice Address - Street 1:2825 RANDOLPH RD
Practice Address - Street 2:
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28211-1018
Practice Address - Country:US
Practice Address - Phone:704-337-1647
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-03-31
Last Update Date:2018-11-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC115157163W00000X
VA0024166512367500000X
NC46267367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
No163W00000XNursing Service ProvidersRegistered Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA010186161Medicaid
NC1235190778Medicaid