Provider Demographics
NPI:1386026284
Name:SCHMUCKLEY, LISA
Entity Type:Individual
Prefix:
First Name:LISA
Middle Name:
Last Name:SCHMUCKLEY
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 1:13110 NE BEECH ST
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97230-2847
Mailing Address - Country:US
Mailing Address - Phone:503-998-5669
Mailing Address - Fax:503-254-5669
Practice Address - Street 1:13110 NE BEECH ST
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97230-2847
Practice Address - Country:US
Practice Address - Phone:503-998-5669
Practice Address - Fax:503-254-5669
Is Sole Proprietor?:No
Enumeration Date:2015-06-26
Last Update Date:2015-06-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR089003023RN163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR098071Medicaid