Healthcare Provider Details

I. General information

NPI: 1740354513
Provider Name (Legal Business Name): LISA A WUNDERLICH CRNA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: LISA A SMITH

II. Dates (important events)

Enumeration Date: 11/20/2006
Last Update Date: 07/18/2024
Certification Date: 07/18/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

100 HITCHCOCK WAY
MANCHESTER NH
03104-4125
US

IV. Provider business mailing address

250 PLEASANT ST
CONCORD NH
03301-7559
US

V. Phone/Fax

Practice location:
  • Phone: 603-695-2500
  • Fax:
Mailing address:
  • Phone: 603-789-9103
  • Fax: 603-227-7832

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number040076-23
License Number StateNH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: