Healthcare Provider Details

I. General information

NPI: 1316930977
Provider Name (Legal Business Name): LISA MATTUCCI-HUNTER CRNA
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: LISA HUNTER CRNA

II. Dates (important events)

Enumeration Date: 08/29/2005
Last Update Date: 06/01/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

234 GOODMAN ST
CINCINNATI OH
45219-2364
US

IV. Provider business mailing address

PO BOX 636256 CENTRAL CREDENTIALING
CINCINNATI OH
45263-6256
US

V. Phone/Fax

Practice location:
  • Phone: 513-558-4194
  • Fax: 513-558-0995
Mailing address:
  • Phone: 513-585-5502
  • Fax: 513-585-5511

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License NumberRN.239700-COA1
License Number StateOH
# 2
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License NumberCOA.05567-NA
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: