Healthcare Provider Details

I. General information

NPI: 1184864498
Provider Name (Legal Business Name): LISA J THOMSON NURSE PRACTITIONER
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: LISA J SNORF AGACNP-BC

II. Dates (important events)

Enumeration Date: 02/26/2009
Last Update Date: 10/17/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1520 S MAIN ST
DAYTON OH
45409-2698
US

IV. Provider business mailing address

1520 S MAIN ST
DAYTON OH
45409-2698
US

V. Phone/Fax

Practice location:
  • Phone: 937-461-5815
  • Fax:
Mailing address:
  • Phone: 937-461-5815
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163WC0200X
TaxonomyCritical Care Medicine Registered Nurse
License NumberRN230360
License Number StateOH
# 2
Primary TaxonomyY
Taxonomy Code363LA2100X
TaxonomyAcute Care Nurse Practitioner
License NumberCOA16504-NP
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: