Provider Demographics
NPI:1801232921
Name:HITOMI, LISA (CPE)
Entity Type:Individual
Prefix:
First Name:LISA
Middle Name:
Last Name:HITOMI
Suffix:
Gender:F
Credentials:CPE
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9915 FAIR OAKS BLVD
Mailing Address - Street 2:
Mailing Address - City:FAIR OAKS
Mailing Address - State:CA
Mailing Address - Zip Code:95628-7433
Mailing Address - Country:US
Mailing Address - Phone:916-224-4247
Mailing Address - Fax:
Practice Address - Street 1:9915 FAIR OAKS BLVD
Practice Address - Street 2:
Practice Address - City:FAIR OAKS
Practice Address - State:CA
Practice Address - Zip Code:95628
Practice Address - Country:US
Practice Address - Phone:916-224-4247
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-05-15
Last Update Date:2022-01-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAL6393172V00000X, 174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
No172V00000XOther Service ProvidersCommunity Health Worker