Provider Demographics
NPI:1518667153
Name:KOONTZ, LISA ANN CALLERY (RN, LMT)
Entity Type:Individual
Prefix:MRS
First Name:LISA
Middle Name:ANN CALLERY
Last Name:KOONTZ
Suffix:
Gender:F
Credentials:RN, LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3521 MUD PUPPY LN SE
Mailing Address - Street 2:
Mailing Address - City:SALEM
Mailing Address - State:OR
Mailing Address - Zip Code:97317-9434
Mailing Address - Country:US
Mailing Address - Phone:503-871-7717
Mailing Address - Fax:
Practice Address - Street 1:3521 MUD PUPPY LN SE
Practice Address - Street 2:
Practice Address - City:SALEM
Practice Address - State:OR
Practice Address - Zip Code:97317-9434
Practice Address - Country:US
Practice Address - Phone:503-871-7717
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-03-02
Last Update Date:2023-03-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR096007075RN163W00000X
OR13994225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist
No163W00000XNursing Service ProvidersRegistered Nurse