Provider Demographics
NPI:1861498495
Name:CLAYTON, LISA RENAY (FNP)
Entity Type:Individual
Prefix:MRS
First Name:LISA
Middle Name:RENAY
Last Name:CLAYTON
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:301 DAVIDSON WAY
Mailing Address - Street 2:
Mailing Address - City:TALENT
Mailing Address - State:OR
Mailing Address - Zip Code:97540-8709
Mailing Address - Country:US
Mailing Address - Phone:541-512-1154
Mailing Address - Fax:541-552-6693
Practice Address - Street 1:1250 SISKIYOU BLVD
Practice Address - Street 2:
Practice Address - City:ASHLAND
Practice Address - State:OR
Practice Address - Zip Code:97520-5001
Practice Address - Country:US
Practice Address - Phone:541-552-6136
Practice Address - Fax:541-552-6693
Is Sole Proprietor?:No
Enumeration Date:2005-06-28
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR227698Medicaid
OR112174Medicare ID - Type Unspecified
OR227698Medicaid