MEDICARE: LISA BOLLA NP

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	363LA2200X	Adult Health Nurse Practitioner	484372	CA

General Provider Information

NPI Number	:	1871628453
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	LISA BOLLA NP

Provider Business Mailing Address
First Line	:	7873 CALLE CARRISA ST
Second Line	:
City	:	HIGHLAND
State	:	CA
Zip	:	92346-6326
Country	:	US
Telephone Number	:	909-558-7163
Fax Number	:

Provider Business Practice Location Address
First Line	:	11234 ANDERSON ST
Second Line	:
City	:	LOMA LINDA
State	:	CA
Zip	:	92354-2804
Country	:	US
Telephone Number	:	909-558-7163
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	02/22/2007
Last Update Date	:	07/08/2007

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