Provider Demographics
NPI:1275579971
Name:WILLEY, LISA K (CRNA)
Entity Type:Individual
Prefix:
First Name:LISA
Middle Name:K
Last Name:WILLEY
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 1:108 SOCIAL ROW
Mailing Address - Street 2:
Mailing Address - City:MARIETTA
Mailing Address - State:OH
Mailing Address - Zip Code:45750-1213
Mailing Address - Country:US
Mailing Address - Phone:740-525-8826
Mailing Address - Fax:
Practice Address - Street 1:401 MATTHEW ST
Practice Address - Street 2:
Practice Address - City:MARIETTA
Practice Address - State:OH
Practice Address - Zip Code:45750-1635
Practice Address - Country:US
Practice Address - Phone:740-568-5427
Practice Address - Fax:740-376-5073
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-21
Last Update Date:2023-08-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHAPRN.CRNA.08338367500000X
OHCOA.08338.NA367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
000000370741OtherANTHEM
P00243361OtherMEDICARE RAILROAD
OH2382498Medicaid
OHP00454431OtherRAILROAD MEDICARE
WV2605306000Medicaid
000000370741OtherANTHEM