Provider Demographics
NPI:1396144234
Name:BOARDMAN, LISA MARIE (MPT)
Entity type:Individual
Prefix:MRS
First Name:LISA
Middle Name:MARIE
Last Name:BOARDMAN
Suffix:
Gender:F
Credentials:MPT
Other - Prefix:MS
Other - First Name:LISA
Other - Middle Name:MARIE
Other - Last Name:HERNANDEZ
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MPT
Mailing Address - Street 1:3550 ROUND BARN BLVD
Mailing Address - Street 2:
Mailing Address - City:SANTA ROSA
Mailing Address - State:CA
Mailing Address - Zip Code:95403-1796
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:3550 ROUND BARN BLVD
Practice Address - Street 2:
Practice Address - City:SANTA ROSA
Practice Address - State:CA
Practice Address - Zip Code:95403-1796
Practice Address - Country:US
Practice Address - Phone:707-486-9362
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-08-16
Last Update Date:2021-11-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA32502225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist