Provider Demographics
NPI:1205167004
Name:FESSENMEYER, LISA
Entity type:Individual
Prefix:MS
First Name:LISA
Middle Name:
Last Name:FESSENMEYER
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:215 SILVERA ST
Mailing Address - Street 2:
Mailing Address - City:MILPITAS
Mailing Address - State:CA
Mailing Address - Zip Code:95035-4101
Mailing Address - Country:US
Mailing Address - Phone:650-817-9070
Mailing Address - Fax:650-246-3838
Practice Address - Street 1:855 VETERANS BLVD
Practice Address - Street 2:
Practice Address - City:REDWOOD CITY
Practice Address - State:CA
Practice Address - Zip Code:94063-1712
Practice Address - Country:US
Practice Address - Phone:650-817-9070
Practice Address - Fax:650-246-3838
Is Sole Proprietor?:No
Enumeration Date:2010-01-19
Last Update Date:2010-01-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPT31061167G00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes167G00000XNursing Service ProvidersLicensed Psychiatric Technician