Provider Demographics
NPI:1457791451
Name:LYSSANOVA, OLGA
Entity Type:Individual
Prefix:
First Name:OLGA
Middle Name:
Last Name:LYSSANOVA
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 1:3666 KEARNY VILLA RD
Mailing Address - Street 2:SUITE #225
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92123-1951
Mailing Address - Country:US
Mailing Address - Phone:858-505-5480
Mailing Address - Fax:
Practice Address - Street 1:3666 KEARNY VILLA RD
Practice Address - Street 2:SUITE #225
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92123-1951
Practice Address - Country:US
Practice Address - Phone:858-505-5480
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-07-05
Last Update Date:2013-07-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225500000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/Technologist