Healthcare Provider Details

I. General information

NPI: 1154519916
Provider Name (Legal Business Name): LISA L. FOWLER CRNA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/05/2007
Last Update Date: 06/03/2025
Certification Date: 06/03/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7630 SOUTHERN BLVD
YOUNGSTOWN OH
44512-5633
US

IV. Provider business mailing address

100 DEBARTOLO PL STE 200
YOUNGSTOWN OH
44512-6095
US

V. Phone/Fax

Practice location:
  • Phone: 330-729-8000
  • Fax: 330-729-8084
Mailing address:
  • Phone: 330-729-8146
  • Fax: 330-965-5229

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License NumberAPRN.CRNA.09671
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: