Healthcare Provider Details

I. General information

NPI: 1881911709
Provider Name (Legal Business Name): LISA ANN MEDEIROS CRNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/02/2010
Last Update Date: 02/19/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

621 RIDGELY AVE SUITE 201
ANNAPOLIS MD
21401-1081
US

IV. Provider business mailing address

621 RIDGELY AVE SUITE 201
ANNAPOLIS MD
21401-1081
US

V. Phone/Fax

Practice location:
  • Phone: 410-224-4887
  • Fax: 410-266-6931
Mailing address:
  • Phone: 410-224-4887
  • Fax: 410-266-6931

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberR089995
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: