Provider Demographics
NPI:1588631550
Name:KOLKA, LISA MARIE (IDC)
Entity Type:Individual
Prefix:
First Name:LISA
Middle Name:MARIE
Last Name:KOLKA
Suffix:
Gender:F
Credentials:IDC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:121 SE VIEWMONT AVE
Mailing Address - Street 2:
Mailing Address - City:CORVALLIS
Mailing Address - State:OR
Mailing Address - Zip Code:97333-1968
Mailing Address - Country:US
Mailing Address - Phone:541-766-3546
Mailing Address - Fax:541-766-6143
Practice Address - Street 1:121 SE VIEWMONT AVE
Practice Address - Street 2:
Practice Address - City:CORVALLIS
Practice Address - State:OR
Practice Address - Zip Code:97333-1968
Practice Address - Country:US
Practice Address - Phone:541-766-3546
Practice Address - Fax:541-766-6143
Is Sole Proprietor?:No
Enumeration Date:2006-03-08
Last Update Date:2016-06-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA1710I1002X
3747A0650X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3747A0650XNursing Service Related ProvidersTechnicianAttendant Care Provider
No1710I1002XOther Service ProvidersMilitary Health Care ProviderIndependent Duty Corpsman