Provider Demographics
NPI:1669186441
Name:GROSSMAN, LISA (RN, IBCLC)
Entity type:Individual
Prefix:
First Name:LISA
Middle Name:
Last Name:GROSSMAN
Suffix:
Gender:F
Credentials:RN, IBCLC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:641 HILLCREST ST
Mailing Address - Street 2:
Mailing Address - City:EL SEGUNDO
Mailing Address - State:CA
Mailing Address - Zip Code:90245-2961
Mailing Address - Country:US
Mailing Address - Phone:310-650-9722
Mailing Address - Fax:424-254-1383
Practice Address - Street 1:641 HILLCREST ST
Practice Address - Street 2:
Practice Address - City:EL SEGUNDO
Practice Address - State:CA
Practice Address - Zip Code:90245-2961
Practice Address - Country:US
Practice Address - Phone:310-650-9722
Practice Address - Fax:424-254-1383
Is Sole Proprietor?:Yes
Enumeration Date:2023-01-06
Last Update Date:2023-01-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA827047163W00000X, 163WH0200X, 163WM0102X, 163WP0200X, 251J00000X, 253Z00000X
CAL-163653251E00000X, 253Z00000X, 163WL0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WL0100XNursing Service ProvidersRegistered NurseLactation Consultant
No163W00000XNursing Service ProvidersRegistered Nurse
No163WH0200XNursing Service ProvidersRegistered NurseHome Health
No163WM0102XNursing Service ProvidersRegistered NurseMaternal Newborn
No163WP0200XNursing Service ProvidersRegistered NursePediatrics
No251E00000XAgenciesHome Health
No251J00000XAgenciesNursing Care
No253Z00000XAgenciesIn Home Supportive Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA827047OtherCA BOARD OF REGISTERED NURSING
CAL-163653OtherIBCLE