Provider Demographics
NPI:1679632475
Name:DEVRIES, LISA (RN)
Entity Type:Individual
Prefix:
First Name:LISA
Middle Name:
Last Name:DEVRIES
Suffix:
Gender:F
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6162 S WILLOW DR STE 100
Mailing Address - Street 2:
Mailing Address - City:GREENWOOD VILLAGE
Mailing Address - State:CO
Mailing Address - Zip Code:80111-5113
Mailing Address - Country:US
Mailing Address - Phone:303-795-4584
Mailing Address - Fax:
Practice Address - Street 1:15400 E 14TH PL
Practice Address - Street 2:
Practice Address - City:AURORA
Practice Address - State:CO
Practice Address - Zip Code:80011-5818
Practice Address - Country:US
Practice Address - Phone:303-478-1999
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-12-07
Last Update Date:2023-02-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO172561163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO36976377Medicaid