Provider Demographics
NPI: | 1790818243 |
---|---|
Name: | DREY, LISA (CNS) |
Entity Type: | Individual |
Prefix: | MS |
First Name: | LISA |
Middle Name: | |
Last Name: | DREY |
Suffix: | |
Gender: | F |
Credentials: | CNS |
Other - Prefix: | |
Other - First Name: | |
Other - Middle Name: | |
Other - Last Name: | |
Other - Suffix: | |
Other - Last Name Type: | |
Other - Credentials: | |
Mailing Address - Street 1: | 1065 NE 125TH ST |
Mailing Address - Street 2: | SUITE 409 |
Mailing Address - City: | NORTH MIAMI |
Mailing Address - State: | FL |
Mailing Address - Zip Code: | 33161-5821 |
Mailing Address - Country: | US |
Mailing Address - Phone: | 888-852-6672 |
Mailing Address - Fax: | 305-891-4228 |
Practice Address - Street 1: | 8671 S QUEBEC ST |
Practice Address - Street 2: | STE 200 |
Practice Address - City: | HIGHLANDS RANCH |
Practice Address - State: | CO |
Practice Address - Zip Code: | 80130-5859 |
Practice Address - Country: | US |
Practice Address - Phone: | 888-852-6672 |
Practice Address - Fax: | 305-891-4228 |
Is Sole Proprietor?: | Yes |
Enumeration Date: | 2007-03-13 |
Last Update Date: | 2011-09-13 |
Deactivation Date: | |
Deactivation Code: | |
Reactivation Date: |
Provider Licenses
State | License ID | Taxonomies |
---|---|---|
CO | 72783 | 363L00000X, 364S00000X |
Provider Taxonomies
Primary? | Code | Type | Classification | Specialization |
---|---|---|---|---|
Yes | 364S00000X | Physician Assistants & Advanced Practice Nursing Providers | Clinical Nurse Specialist | |
No | 363L00000X | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner |
Provider Identifiers
State | Identifier ID | ID Type | Issuer |
---|---|---|---|
CO | 26627311 | Medicaid | |
CO | 26627311 | Medicaid |