Healthcare Provider Details

I. General information

NPI: 1033199559
Provider Name (Legal Business Name): LISA ANN PETTY CRNA
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/19/2006
Last Update Date: 07/10/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9040 JACKSON AVE
TACOMA WA
98431-0001
US

IV. Provider business mailing address

MADIGAN ARMY MEDICAL CENTER 9040 REID ST., ATTN: MCHJ-QCR
TACOMA WA
98431-0001
US

V. Phone/Fax

Practice location:
  • Phone: 253-968-2252
  • Fax: 253-968-3278
Mailing address:
  • Phone: 253-968-2252
  • Fax: 253-968-3278

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number107635
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: