Provider Demographics
NPI:1780849935
Name:LOMBARD, ELISA R (ARNP)
Entity Type:Individual
Prefix:
First Name:ELISA
Middle Name:R
Last Name:LOMBARD
Suffix:
Gender:F
Credentials:ARNP
Other - Prefix:
Other - First Name:ELISA
Other - Middle Name:R
Other - Last Name:ROTH
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:ARNP
Mailing Address - Street 1:PO BOX 21249
Mailing Address - Street 2:
Mailing Address - City:SEATTLE
Mailing Address - State:WA
Mailing Address - Zip Code:98111-3249
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:715 9TH AVE
Practice Address - Street 2:
Practice Address - City:SEATTLE
Practice Address - State:WA
Practice Address - Zip Code:98104-2066
Practice Address - Country:US
Practice Address - Phone:206-580-6844
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-07-26
Last Update Date:2022-04-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAAP60031345363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA1780849935Medicaid