Healthcare Provider Details

I. General information

NPI: 1962580241
Provider Name (Legal Business Name): LISA R. LOSACK BSN, CNOR, CRNFA
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/02/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1100 E LAKE ST SUITE 230
TYLER TX
75701-3343
US

IV. Provider business mailing address

PO BOX 1848 519 SUNNYSIDE DRIVE
CHANDLER TX
75758-1848
US

V. Phone/Fax

Practice location:
  • Phone: 903-539-0230
  • Fax: 903-597-3015
Mailing address:
  • Phone: 903-849-6475
  • Fax: 903-849-6475

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WR0006X
TaxonomyRegistered Nurse First Assistant
License Number613274
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: