Provider Demographics
NPI:1316192420
Name:BREECE, LISA M (CRNA)
Entity Type:Individual
Prefix:
First Name:LISA
Middle Name:M
Last Name:BREECE
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 1:3323 HEATHERWOOD TRCE
Mailing Address - Street 2:
Mailing Address - City:CLARKSVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:37040-5758
Mailing Address - Country:US
Mailing Address - Phone:210-363-1853
Mailing Address - Fax:
Practice Address - Street 1:3323 HEATHERWOOD TRCE
Practice Address - Street 2:
Practice Address - City:CLARKSVILLE
Practice Address - State:TN
Practice Address - Zip Code:37040-5758
Practice Address - Country:US
Practice Address - Phone:210-363-1853
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-11-18
Last Update Date:2023-07-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
HIRN-53790163W00000X
KY3015412367500000X
TN13955367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
No163W00000XNursing Service ProvidersRegistered Nurse