Provider Demographics
NPI:1497731707
Name:HARTLEY, LISA M (RN BSN CDE)
Entity Type:Individual
Prefix:MS
First Name:LISA
Middle Name:M
Last Name:HARTLEY
Suffix:
Gender:F
Credentials:RN BSN CDE
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1100 MARSHALL WAY
Mailing Address - Street 2:
Mailing Address - City:PLACERVILLE
Mailing Address - State:CA
Mailing Address - Zip Code:95667-6533
Mailing Address - Country:US
Mailing Address - Phone:530-626-2990
Mailing Address - Fax:530-626-2992
Practice Address - Street 1:681 MAIN ST
Practice Address - Street 2:STE 100
Practice Address - City:PLACERVILLE
Practice Address - State:CA
Practice Address - Zip Code:95667-5736
Practice Address - Country:US
Practice Address - Phone:530-626-2990
Practice Address - Fax:530-626-2992
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-12-19
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA308969133V00000X
CA20210187163WD0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered133V00000XDietary & Nutritional Service ProvidersDietitian, Registered
Not Answered163WD0400XNursing Service ProvidersRegistered NurseDiabetes Educator
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA308969OtherRN
CA20210187OtherCDE