Healthcare Provider Details

I. General information

NPI: 1497051429
Provider Name (Legal Business Name): LISA GEORGE
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/09/2011
Last Update Date: 02/09/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

705 PALM AVE
IMPERIAL BEACH CA
91932-1229
US

IV. Provider business mailing address

10188 FABLED WATERS CT
SPRING VALLEY CA
91977-3458
US

V. Phone/Fax

Practice location:
  • Phone: 619-424-5106
  • Fax: 619-424-3648
Mailing address:
  • Phone: 619-948-7762
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP2300X
TaxonomyPrimary Care Nurse Practitioner
License Number19868
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: