Healthcare Provider Details

I. General information

NPI: 1861613119
Provider Name (Legal Business Name): LYZA J ANDERSON CRNA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/02/2007
Last Update Date: 05/20/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

242 9TH AVENUE DR NE
HICKORY NC
28601-3828
US

IV. Provider business mailing address

1100 TROON RD
LAKE OSWEGO OR
97034-2836
US

V. Phone/Fax

Practice location:
  • Phone: 828-322-7305
  • Fax:
Mailing address:
  • Phone: 404-918-9019
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License NumberRN144880
License Number StateGA
# 2
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number201508616CRNA
License Number StateOR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: