Healthcare Provider Details

I. General information

NPI: 1497761183
Provider Name (Legal Business Name): LISA BERRY LASATER CRNA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: LISA BERRY CRNA

II. Dates (important events)

Enumeration Date: 08/01/2006
Last Update Date: 05/02/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1400 US HIGHWAY 61
FESTUS MO
63028-4100
US

IV. Provider business mailing address

PO BOX 350
CRYSTAL CITY MO
63019-0350
US

V. Phone/Fax

Practice location:
  • Phone: 636-933-1000
  • Fax:
Mailing address:
  • Phone: 636-933-1000
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number072604
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: