Provider Demographics
NPI:1942788989
Name:BAUM, LISA ANN (RN, CDDN)
Entity Type:Individual
Prefix:
First Name:LISA
Middle Name:ANN
Last Name:BAUM
Suffix:
Gender:F
Credentials:RN, CDDN
Other - Prefix:
Other - First Name:LISA
Other - Middle Name:ANN
Other - Last Name:MEISSNER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:RN
Mailing Address - Street 1:7000 78TH AVE N
Mailing Address - Street 2:
Mailing Address - City:BROOKLYN PARK
Mailing Address - State:MN
Mailing Address - Zip Code:55445-2744
Mailing Address - Country:US
Mailing Address - Phone:612-718-6230
Mailing Address - Fax:763-416-9120
Practice Address - Street 1:6840 78TH AVE N
Practice Address - Street 2:
Practice Address - City:BROOKLYN PARK
Practice Address - State:MN
Practice Address - Zip Code:55445-2760
Practice Address - Country:US
Practice Address - Phone:612-718-6230
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-08-01
Last Update Date:2018-08-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA94145611163W00000X
MNR146370-1163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA94145611OtherNURSING LICENSE
MNR146370-1OtherNURSING LICENSE
MN2015015OtherCERTIFICATION DEVELOPMENTAL DISABILITY NURSE - NATIONAL ASSOCIATION