Provider Demographics
NPI:1629228929
Name:GATES, LISA A (RN BSN)
Entity Type:Individual
Prefix:
First Name:LISA
Middle Name:A
Last Name:GATES
Suffix:
Gender:F
Credentials:RN BSN
Other - Prefix:
Other - First Name:
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Other - Last Name:
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Mailing Address - Street 1:3033 KETTERING BLVD STE 100
Mailing Address - Street 2:
Mailing Address - City:MORAINE
Mailing Address - State:OH
Mailing Address - Zip Code:45439-1948
Mailing Address - Country:US
Mailing Address - Phone:937-293-2133
Mailing Address - Fax:855-252-2435
Practice Address - Street 1:3033 KETTERING BLVD STE 100
Practice Address - Street 2:
Practice Address - City:MORAINE
Practice Address - State:OH
Practice Address - Zip Code:45439
Practice Address - Country:US
Practice Address - Phone:937-293-2133
Practice Address - Fax:855-252-2435
Is Sole Proprietor?:Yes
Enumeration Date:2008-09-23
Last Update Date:2020-04-21
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
OHRN 207875163W00000X
OHAPRN.CNP.024014363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No163W00000XNursing Service ProvidersRegistered Nurse