Provider Demographics
NPI:1346560588
Name:DAVIS, LISA SUSAN (CRNA, APRN)
Entity Type:Individual
Prefix:
First Name:LISA
Middle Name:SUSAN
Last Name:DAVIS
Suffix:
Gender:F
Credentials:CRNA, APRN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:23 MOUNTAINSIDE DR
Mailing Address - Street 2:
Mailing Address - City:NEWBURY
Mailing Address - State:NH
Mailing Address - Zip Code:03255-5205
Mailing Address - Country:US
Mailing Address - Phone:603-727-6253
Mailing Address - Fax:
Practice Address - Street 1:35 MILES ST
Practice Address - Street 2:
Practice Address - City:DAMARISCOTTA
Practice Address - State:ME
Practice Address - Zip Code:04543-4047
Practice Address - Country:US
Practice Address - Phone:207-563-1234
Practice Address - Fax:603-228-2113
Is Sole Proprietor?:No
Enumeration Date:2010-06-10
Last Update Date:2021-01-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MERNA173018367500000X
NH06244323367500000X
PARN529981L367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
NH3096163Medicaid
NH3096163Medicaid