Healthcare Provider Details

I. General information

NPI: 1902643745
Provider Name (Legal Business Name): LISA DAVIS RN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/10/2024
Last Update Date: 07/10/2024
Certification Date: 07/10/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4101 WOOLWORTH AVE
OMAHA NE
68105-1850
US

IV. Provider business mailing address

4101 WOOLWORTH AVE
OMAHA NE
68105-1850
US

V. Phone/Fax

Practice location:
  • Phone: 402-930-7816
  • Fax: 612-725-1273
Mailing address:
  • Phone: 402-930-7816
  • Fax: 612-725-1273

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WC0400X
TaxonomyCase Management Registered Nurse
License Number82519
License Number StateNE

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: