Healthcare Provider Details

I. General information

NPI: 1104579911
Provider Name (Legal Business Name): LISA HUDSON
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/01/2022
Last Update Date: 05/02/2023
Certification Date: 05/02/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

410 JONES ST
UKIAH CA
95482-5414
US

IV. Provider business mailing address

410 JONES ST
UKIAH CA
95482-5414
US

V. Phone/Fax

Practice location:
  • Phone: 707-463-0405
  • Fax: 707-313-1274
Mailing address:
  • Phone: 707-463-0405
  • Fax: 707-313-1274

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code172V00000X
TaxonomyCommunity Health Worker
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: