Healthcare Provider Details

I. General information

NPI: 1669196424
Provider Name (Legal Business Name): LISA MARIE BAKER FNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/26/2022
Last Update Date: 01/14/2025
Certification Date: 01/14/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2497 HERNDON AVE STE 102
CLOVIS CA
93611-8977
US

IV. Provider business mailing address

2497 HERNDON AVE STE 102
CLOVIS CA
93611-8977
US

V. Phone/Fax

Practice location:
  • Phone: 559-450-8886
  • Fax: 559-450-8887
Mailing address:
  • Phone: 559-450-8886
  • Fax: 559-450-8887

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number95022616
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number95037402
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: