Healthcare Provider Details

I. General information

NPI: 1912956970
Provider Name (Legal Business Name): LISA MICHELLE GERVING RN
Entity Type: Individual
Gender: Female
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 05/08/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

BOX 105109 USA MEDDAC
FORT IRWIN CA
92310
US

IV. Provider business mailing address

5094 B SUPERIOR VALLEY
FORT IRWIN CA
92310
US

V. Phone/Fax

Practice location:
  • Phone: 760-380-3144
  • Fax:
Mailing address:
  • Phone: 760-386-0324
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License NumberR23303
License Number StateND

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: