Provider Demographics
NPI:1356496004
Name:BOUGHNER, LISA
Entity Type:Individual
Prefix:
First Name:LISA
Middle Name:
Last Name:BOUGHNER
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1872 MILLPOND CT
Mailing Address - Street 2:
Mailing Address - City:RENO
Mailing Address - State:NV
Mailing Address - Zip Code:89523-2057
Mailing Address - Country:US
Mailing Address - Phone:775-787-1339
Mailing Address - Fax:
Practice Address - Street 1:3700 GRANT DR STE A
Practice Address - Street 2:
Practice Address - City:RENO
Practice Address - State:NV
Practice Address - Zip Code:89509-7349
Practice Address - Country:US
Practice Address - Phone:775-829-4700
Practice Address - Fax:775-829-4710
Is Sole Proprietor?:No
Enumeration Date:2007-01-24
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NV1751225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NV29-6505Medicare ID - Type Unspecified