Healthcare Provider Details

I. General information

NPI: 1104198316
Provider Name (Legal Business Name): LISA SHAY BONO CRNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: LISA FULLER

II. Dates (important events)

Enumeration Date: 02/02/2012
Last Update Date: 09/15/2021
Certification Date: 09/15/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1 NOLTE DR
KITTANNING PA
16201-7111
US

IV. Provider business mailing address

1 NOLTE DR
KITTANNING PA
16201-7111
US

V. Phone/Fax

Practice location:
  • Phone: 833-246-7662
  • Fax: 724-671-1706
Mailing address:
  • Phone: 833-246-7662
  • Fax: 724-671-1706

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberSP011517
License Number StatePA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: