Provider Demographics
NPI:1831663426
Name:POWELL, LISA LEVIDA (LVN)
Entity Type:Individual
Prefix:MS
First Name:LISA
Middle Name:LEVIDA
Last Name:POWELL
Suffix:
Gender:F
Credentials:LVN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2860 NIOBRARA AVE
Mailing Address - Street 2:
Mailing Address - City:STOCKTON
Mailing Address - State:CA
Mailing Address - Zip Code:95206-6418
Mailing Address - Country:US
Mailing Address - Phone:510-253-3832
Mailing Address - Fax:
Practice Address - Street 1:1133 COLOMA WAY STE C
Practice Address - Street 2:
Practice Address - City:ROSEVILLE
Practice Address - State:CA
Practice Address - Zip Code:95661-4480
Practice Address - Country:US
Practice Address - Phone:916-774-6647
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-01-16
Last Update Date:2019-01-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA235848164X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164X00000XNursing Service ProvidersLicensed Vocational Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA10OtherMETHADONE CLINIC