Healthcare Provider Details

I. General information

NPI: 1992679617
Provider Name (Legal Business Name): LISA ANN NAZARENKO RN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/04/2025
Last Update Date: 10/04/2025
Certification Date: 10/04/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

300 MAIN ST
LEWISTON ME
04240-7041
US

IV. Provider business mailing address

160 LEWIS HILL RD
BOWDOIN ME
04287-7335
US

V. Phone/Fax

Practice location:
  • Phone: 207-795-0111
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License NumberRN47052
License Number StateME

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: