Healthcare Provider Details

I. General information

NPI: 1114909256
Provider Name (Legal Business Name): LISA RUBENBAUER RN
Entity Type: Individual
Gender: Female
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 11/15/2005
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3345 N WINDSONG DR
PRESCOTT VALLEY AZ
86314-2283
US

IV. Provider business mailing address

642 DAMERON DR
PRESCOTT AZ
86301-2411
US

V. Phone/Fax

Practice location:
  • Phone: 928-445-5211
  • Fax: 928-776-8484
Mailing address:
  • Phone: 928-445-5211
  • Fax: 928-776-8484

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WP0808X
TaxonomyPsychiatric/Mental Health Registered Nurse
License NumberRN128437
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: