Healthcare Provider Details

I. General information

NPI: 1295599702
Provider Name (Legal Business Name): LISA ANN ROUSSEAU
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: LISA ANN LOPEZ

II. Dates (important events)

Enumeration Date: 02/06/2024
Last Update Date: 02/06/2024
Certification Date: 02/06/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3750 ROHNERVILLE RD
FORTUNA CA
95540-3118
US

IV. Provider business mailing address

1275 8TH ST
ARCATA CA
95521-5770
US

V. Phone/Fax

Practice location:
  • Phone: 707-725-6101
  • Fax: 707-725-2978
Mailing address:
  • Phone: 707-826-8633
  • Fax: 707-826-6838

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number95258711
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: