Provider Demographics
NPI:1285919373
Name:PAUL, LISA MARIE M (CRNA)
Entity type:Individual
Prefix:
First Name:LISA MARIE
Middle Name:M
Last Name:PAUL
Suffix:
Gender:F
Credentials:CRNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:425 LEWIS HARGETT CIR
Mailing Address - Street 2:
Mailing Address - City:LEXINGTON
Mailing Address - State:KY
Mailing Address - Zip Code:40503-3590
Mailing Address - Country:US
Mailing Address - Phone:859-268-1030
Mailing Address - Fax:859-269-4120
Practice Address - Street 1:111 COLCHESTER AVE
Practice Address - Street 2:
Practice Address - City:BURLINGTON
Practice Address - State:VT
Practice Address - Zip Code:05401-1473
Practice Address - Country:US
Practice Address - Phone:802-847-2415
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-10-20
Last Update Date:2018-09-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA636631163W00000X
MA256932163W00000X
NY607721163W00000X
VT88045163W00000X
KY3010203367500000X
VT88148367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
No163W00000XNursing Service ProvidersRegistered Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA95000710OtherCRNA LICENSE