Provider Demographics
NPI:1700368594
Name:PALOMO PORTILLO, LISA ANN
Entity Type:Individual
Prefix:
First Name:LISA
Middle Name:ANN
Last Name:PALOMO PORTILLO
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4342 DESERT VIEW DR
Mailing Address - Street 2:
Mailing Address - City:SAN ANTONIO
Mailing Address - State:TX
Mailing Address - Zip Code:78217-3630
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:4342 DESERT VIEW DR
Practice Address - Street 2:
Practice Address - City:SAN ANTONIO
Practice Address - State:TX
Practice Address - Zip Code:78217-3630
Practice Address - Country:US
Practice Address - Phone:210-383-0057
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-08-29
Last Update Date:2018-08-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX171418164X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164X00000XNursing Service ProvidersLicensed Vocational Nurse