Healthcare Provider Details

I. General information

NPI: 1962888230
Provider Name (Legal Business Name): MS. LISA SPERRY
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/10/2015
Last Update Date: 08/10/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

555 CEDAR ST
SAINT PAUL MN
55101-2209
US

IV. Provider business mailing address

555 CEDAR ST
SAINT PAUL MN
55101-2209
US

V. Phone/Fax

Practice location:
  • Phone: 651-266-1343
  • Fax: 651-266-1384
Mailing address:
  • Phone: 651-266-1343
  • Fax: 651-266-1384

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License NumberR 127135-9
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: