Provider Demographics
NPI:1942508635
Name:BOFFA, LISA ANNE (FNP, PMHNP, ND)
Entity Type:Individual
Prefix:
First Name:LISA
Middle Name:ANNE
Last Name:BOFFA
Suffix:
Gender:F
Credentials:FNP, PMHNP, ND
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:715 S 1ST ST
Mailing Address - Street 2:
Mailing Address - City:MONTROSE
Mailing Address - State:CO
Mailing Address - Zip Code:81401-3914
Mailing Address - Country:US
Mailing Address - Phone:970-964-8653
Mailing Address - Fax:970-249-8495
Practice Address - Street 1:715 S 1ST ST
Practice Address - Street 2:
Practice Address - City:MONTROSE
Practice Address - State:CO
Practice Address - Zip Code:81401-3914
Practice Address - Country:US
Practice Address - Phone:970-249-0442
Practice Address - Fax:970-249-8495
Is Sole Proprietor?:No
Enumeration Date:2011-03-04
Last Update Date:2022-12-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CONP-990063363LF0000X
COAPN.0990063-NP363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO57009571Medicaid