Healthcare Provider Details

I. General information

NPI: 1346560588
Provider Name (Legal Business Name): LISA SUSAN DAVIS CRNA, APRN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/10/2010
Last Update Date: 01/15/2021
Certification Date: 01/15/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

35 MILES ST
DAMARISCOTTA ME
04543-4047
US

IV. Provider business mailing address

23 MOUNTAINSIDE DR
NEWBURY NH
03255-5205
US

V. Phone/Fax

Practice location:
  • Phone: 207-563-1234
  • Fax: 603-228-2113
Mailing address:
  • Phone: 603-727-6253
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License NumberRNA173018
License Number StateME
# 2
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number06244323
License Number StateNH
# 3
Primary TaxonomyN
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License NumberRN529981L
License Number StatePA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: