Healthcare Provider Details

I. General information

NPI: 1245942937
Provider Name (Legal Business Name): LISA VICTORIA PUALUAN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/14/2022
Last Update Date: 12/14/2022
Certification Date: 12/14/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1516 VIRGINIA RANCH RD
GARDNERVILLE NV
89410-5794
US

IV. Provider business mailing address

1516 VIRGINIA RANCH RD
GARDNERVILLE NV
89410-5794
US

V. Phone/Fax

Practice location:
  • Phone: 775-783-4823
  • Fax: 775-783-4806
Mailing address:
  • Phone: 775-783-4823
  • Fax: 775-783-4806

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number861023
License Number StateNV

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: