Healthcare Provider Details

I. General information

NPI: 1992970552
Provider Name (Legal Business Name): LISA LINN SANTO DOMINGO CRNP-PEDIATRICS
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: LISA LINN SEAMAN CRNP-PEDIATRICS

II. Dates (important events)

Enumeration Date: 04/24/2008
Last Update Date: 08/10/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

600 N WOLFE ST BRADY 320
BALTIMORE MD
21287-0005
US

IV. Provider business mailing address

600 N WOLFE ST BRADY 320
BALTIMORE MD
21287-0005
US

V. Phone/Fax

Practice location:
  • Phone: 410-955-8769
  • Fax: 410-955-1464
Mailing address:
  • Phone: 410-955-8769
  • Fax: 410-955-1464

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP0200X
TaxonomyPediatric Nurse Practitioner
License NumberR175012
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: