Healthcare Provider Details

I. General information

NPI: 1740912054
Provider Name (Legal Business Name): ANDREA ANN LYSAK RNFA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/27/2022
Last Update Date: 06/27/2022
Certification Date: 06/15/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10121 PINE AVE
TRUCKEE CA
96161-4856
US

IV. Provider business mailing address

214 FIR STREET
SHERWOOD PARK ALBERTA
T8A 2A4
CA

V. Phone/Fax

Practice location:
  • Phone: 530-587-6011
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WR0006X
TaxonomyRegistered Nurse First Assistant
License Number606606
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: