Healthcare Provider Details

I. General information

NPI: 1447359955
Provider Name (Legal Business Name): LISA ANN DURETTE MD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/21/2006
Last Update Date: 06/02/2020
Certification Date: 06/02/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6375 W CHARLESTON BLVD STE A-100
LAS VEGAS NV
89146-1139
US

IV. Provider business mailing address

3016 W CHARLESTON BLVD STE 100
LAS VEGAS NV
89102-1973
US

V. Phone/Fax

Practice location:
  • Phone: 702-253-0818
  • Fax: 702-253-9625
Mailing address:
  • Phone: 702-780-7118
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2084P0804X
TaxonomyChild & Adolescent Psychiatry Physician
License Number10869
License Number StateNV

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: