Provider Demographics
NPI:1215285044
Name:LUSARDI, JILLIAN JOYCE (CRNA)
Entity type:Individual
Prefix:
First Name:JILLIAN
Middle Name:JOYCE
Last Name:LUSARDI
Suffix:
Gender:F
Credentials:CRNA
Other - Prefix:
Other - First Name:JILLIAN
Other - Middle Name:JOYCE
Other - Last Name:ISIP
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:CRNA
Mailing Address - Street 1:750 STEPHENSON HWY
Mailing Address - Street 2:BEAUMONT PAYOR CONTRACT SERVICES
Mailing Address - City:TROY
Mailing Address - State:MI
Mailing Address - Zip Code:48083-1103
Mailing Address - Country:US
Mailing Address - Phone:248-577-3520
Mailing Address - Fax:
Practice Address - Street 1:3601 W 13 MILE RD
Practice Address - Street 2:
Practice Address - City:ROYAL OAK
Practice Address - State:MI
Practice Address - Zip Code:48073-6712
Practice Address - Country:US
Practice Address - Phone:248-577-3520
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-08-28
Last Update Date:2013-02-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4704263498367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered