Healthcare Provider Details

I. General information

NPI: 1477761419
Provider Name (Legal Business Name): NINA LYSKI LMT
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/21/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1715 E BURNSIDE ST
PORTLAND OR
97214-1531
US

IV. Provider business mailing address

3081 SE PINE ST
PORTLAND OR
97214-1957
US

V. Phone/Fax

Practice location:
  • Phone: 503-504-1238
  • Fax:
Mailing address:
  • Phone: 503-504-1238
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code174400000X
TaxonomySpecialist
License Number4454
License Number StateOR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: