Provider Demographics
NPI:1669703641
Name:MATLOCK, LISA RENEE (FNP)
Entity type:Individual
Prefix:MRS
First Name:LISA
Middle Name:RENEE
Last Name:MATLOCK
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:
Other - First Name:LISA
Other - Middle Name:RENEE
Other - Last Name:LOGIUDICE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:890 OAK ST SE
Mailing Address - Street 2:
Mailing Address - City:SALEM
Mailing Address - State:OR
Mailing Address - Zip Code:97301-3905
Mailing Address - Country:US
Mailing Address - Phone:503-561-5200
Mailing Address - Fax:
Practice Address - Street 1:2020 CAPITOL ST NE
Practice Address - Street 2:
Practice Address - City:SALEM
Practice Address - State:OR
Practice Address - Zip Code:97301-0644
Practice Address - Country:US
Practice Address - Phone:503-399-2424
Practice Address - Fax:503-375-7429
Is Sole Proprietor?:No
Enumeration Date:2010-01-15
Last Update Date:2022-03-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR201050187NP363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
ORR174975Medicare PIN