Provider Demographics
NPI:1952403990
Name:TAYLOR, LISA D (NP)
Entity Type:Individual
Prefix:
First Name:LISA
Middle Name:D
Last Name:TAYLOR
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 320
Mailing Address - Street 2:
Mailing Address - City:SILETZ
Mailing Address - State:OR
Mailing Address - Zip Code:97380-0320
Mailing Address - Country:US
Mailing Address - Phone:541-444-1030
Mailing Address - Fax:541-444-9695
Practice Address - Street 1:200 GWEE-SHUT ROAD
Practice Address - Street 2:
Practice Address - City:SILETZ
Practice Address - State:OR
Practice Address - Zip Code:97380
Practice Address - Country:US
Practice Address - Phone:541-444-1030
Practice Address - Fax:541-444-9695
Is Sole Proprietor?:No
Enumeration Date:2006-09-01
Last Update Date:2017-02-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR087006473RN163W00000X
OR087006473N1363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No163W00000XNursing Service ProvidersRegistered Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR273019Medicaid
OR273019Medicaid
S96523Medicare UPIN