Healthcare Provider Details

I. General information

NPI: 1770825747
Provider Name (Legal Business Name): LISA HALL MCDONALD NP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: LISA DIANE VILLABONA NP

II. Dates (important events)

Enumeration Date: 03/18/2013
Last Update Date: 04/02/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2540 CENTREVILLE RD
CENTREVILLE MD
21617-2681
US

IV. Provider business mailing address

PO BOX 778
EASTON MD
21601-8914
US

V. Phone/Fax

Practice location:
  • Phone: 410-758-4432
  • Fax: 410-758-1938
Mailing address:
  • Phone: 410-763-8787
  • Fax: 410-763-8788

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberR118699
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: