Provider Demographics
NPI:1467488312
Name:AVERILL, LISA CHRISTINE (CNM)
Entity Type:Individual
Prefix:
First Name:LISA
Middle Name:CHRISTINE
Last Name:AVERILL
Suffix:
Gender:F
Credentials:CNM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2700 SE STRATUS AVE
Mailing Address - Street 2:SUITE 301
Mailing Address - City:MCMINNVILLE
Mailing Address - State:OR
Mailing Address - Zip Code:97128
Mailing Address - Country:US
Mailing Address - Phone:503-474-1148
Mailing Address - Fax:503-434-6148
Practice Address - Street 1:2700 SE STRATUS AVE
Practice Address - Street 2:SUITE 301
Practice Address - City:MCMINNVILLE
Practice Address - State:OR
Practice Address - Zip Code:97128
Practice Address - Country:US
Practice Address - Phone:503-474-1148
Practice Address - Fax:503-434-6148
Is Sole Proprietor?:No
Enumeration Date:2006-06-23
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR20050058NP367A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367A00000XPhysician Assistants & Advanced Practice Nursing ProvidersAdvanced Practice Midwife
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR292902Medicaid
OR292902Medicaid