Provider Demographics
NPI:1619061447
Name:KALTENBAUGH, LISA L (CRNFA)
Entity Type:Individual
Prefix:
First Name:LISA
Middle Name:L
Last Name:KALTENBAUGH
Suffix:
Gender:F
Credentials:CRNFA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:307 SAINT JOHNS WAY STE 1
Mailing Address - Street 2:
Mailing Address - City:LEWISTON
Mailing Address - State:ID
Mailing Address - Zip Code:83501-2435
Mailing Address - Country:US
Mailing Address - Phone:208-746-5132
Mailing Address - Fax:208-746-0087
Practice Address - Street 1:307 SAINT JOHNS WAY STE 1
Practice Address - Street 2:
Practice Address - City:LEWISTON
Practice Address - State:ID
Practice Address - Zip Code:83501-2435
Practice Address - Country:US
Practice Address - Phone:208-746-5132
Practice Address - Fax:208-746-0087
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-03
Last Update Date:2010-08-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ID16540163WR0006X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WR0006XNursing Service ProvidersRegistered NurseRegistered Nurse First Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID000010135951OtherBLUE SHIELD
ID32268OtherBLUE CROSS