Healthcare Provider Details

I. General information

NPI: 1972458081
Provider Name (Legal Business Name): LISA RYAN CARLSON RN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: LISA A RYAN RN

II. Dates (important events)

Enumeration Date: 03/03/2026
Last Update Date: 08/03/2026
Certification Date: 08/03/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1435 N MCDOWELL BLVD
PETALUMA CA
94954-6547
US

IV. Provider business mailing address

1435 N MCDOWELL BLVD
PETALUMA CA
94954-6547
US

V. Phone/Fax

Practice location:
  • Phone: 707-309-7300
  • Fax:
Mailing address:
  • Phone: 707-309-7300
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number95040711
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: