Provider Demographics
NPI:1477761419
Name:LYSKI, NINA (LMT)
Entity type:Individual
Prefix:
First Name:NINA
Middle Name:
Last Name:LYSKI
Suffix:
Gender:F
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3081 SE PINE ST
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97214-1957
Mailing Address - Country:US
Mailing Address - Phone:503-504-1238
Mailing Address - Fax:
Practice Address - Street 1:1715 E BURNSIDE ST
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97214-1531
Practice Address - Country:US
Practice Address - Phone:503-504-1238
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-21
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR4454174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist