Provider Demographics
NPI:1801843941
Name:YOUNGBLOOD, LISA ANNE (RN NP)
Entity Type:Individual
Prefix:
First Name:LISA
Middle Name:ANNE
Last Name:YOUNGBLOOD
Suffix:
Gender:F
Credentials:RN NP
Other - Prefix:
Other - First Name:LISA
Other - Middle Name:ANNE
Other - Last Name:CATAREVAS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:103 HALF MOON CIR APT C2
Mailing Address - Street 2:
Mailing Address - City:HYPOLUXO
Mailing Address - State:FL
Mailing Address - Zip Code:33462-5494
Mailing Address - Country:US
Mailing Address - Phone:515-381-8825
Mailing Address - Fax:
Practice Address - Street 1:1055 WILSHIRE BLVD STE 1705
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90017-5600
Practice Address - Country:US
Practice Address - Phone:310-871-0670
Practice Address - Fax:619-667-0815
Is Sole Proprietor?:No
Enumeration Date:2006-05-27
Last Update Date:2023-02-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CARN481125163W00000X
CANP11105363LP0808X
FL11011940363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
No163W00000XNursing Service ProvidersRegistered Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
S98739Medicare UPIN
CAW416Medicare PIN
CAWNP11105AMedicare PIN