Provider Demographics
NPI:1104638691
Name:BOZEMAN, LISA RENEE
Entity type:Individual
Prefix:
First Name:LISA
Middle Name:RENEE
Last Name:BOZEMAN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1333 BROOKEVILLE AVE APT C
Mailing Address - Street 2:
Mailing Address - City:COLUMBUS
Mailing Address - State:OH
Mailing Address - Zip Code:43229-1248
Mailing Address - Country:US
Mailing Address - Phone:220-246-2149
Mailing Address - Fax:
Practice Address - Street 1:1349 BROOKEVILLE AVE APT A
Practice Address - Street 2:
Practice Address - City:COLUMBUS
Practice Address - State:OH
Practice Address - Zip Code:43229-1613
Practice Address - Country:US
Practice Address - Phone:230-246-2149
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-01-22
Last Update Date:2025-01-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes374U00000XNursing Service Related ProvidersHome Health Aide