Provider Demographics
NPI:1407302540
Name:DOHERTY, LISA DIANNE (RN, BSN)
Entity Type:Individual
Prefix:
First Name:LISA
Middle Name:DIANNE
Last Name:DOHERTY
Suffix:
Gender:F
Credentials:RN, BSN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5174 PERRY ST NE
Mailing Address - Street 2:
Mailing Address - City:KEIZER
Mailing Address - State:OR
Mailing Address - Zip Code:97303-2496
Mailing Address - Country:US
Mailing Address - Phone:503-507-0013
Mailing Address - Fax:503-961-1283
Practice Address - Street 1:4080 REED RD SE
Practice Address - Street 2:
Practice Address - City:SALEM
Practice Address - State:OR
Practice Address - Zip Code:97302-1357
Practice Address - Country:US
Practice Address - Phone:503-507-0013
Practice Address - Fax:503-961-1283
Is Sole Proprietor?:Yes
Enumeration Date:2016-08-29
Last Update Date:2016-08-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR201240192RN163WC1500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WC1500XNursing Service ProvidersRegistered NurseCommunity Health