Provider Demographics
NPI:1760079883
Name:PUFKY, LISA M I (RN)
Entity Type:Individual
Prefix:
First Name:LISA
Middle Name:M
Last Name:PUFKY
Suffix:I
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 1:12148 RANCHO BERNARDO RD UNIT A
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92128-7014
Mailing Address - Country:US
Mailing Address - Phone:760-237-9469
Mailing Address - Fax:
Practice Address - Street 1:12148 RANCHO BERNARDO RD
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92128-7014
Practice Address - Country:US
Practice Address - Phone:760-237-9469
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-12-22
Last Update Date:2020-12-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA621751163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA621751Other621751