Healthcare Provider Details

I. General information

NPI: 1902945686
Provider Name (Legal Business Name): LISA DURHAM LVN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/06/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1700 IOWA AVE SUITE 230
RIVERSIDE CA
92507-2420
US

IV. Provider business mailing address

200 E ALESSANDRO BLVD APT 67
RIVERSIDE CA
92508-6180
US

V. Phone/Fax

Practice location:
  • Phone: 951-369-8604
  • Fax: 951-715-4594
Mailing address:
  • Phone: 951-789-0838
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code164X00000X
TaxonomyLicensed Vocational Nurse
License NumberVN207886
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: