Provider Demographics
NPI:1386881829
Name:ROBERTS, LISA
Entity type:Individual
Prefix:
First Name:LISA
Middle Name:
Last Name:ROBERTS
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 1:3020 RUCKER AVE
Mailing Address - Street 2:106
Mailing Address - City:EVERETT
Mailing Address - State:WA
Mailing Address - Zip Code:98201-3900
Mailing Address - Country:US
Mailing Address - Phone:425-252-8816
Mailing Address - Fax:425-339-8707
Practice Address - Street 1:3020 RUCKER AVE
Practice Address - Street 2:106
Practice Address - City:EVERETT
Practice Address - State:WA
Practice Address - Zip Code:98201-3900
Practice Address - Country:US
Practice Address - Phone:425-252-8816
Practice Address - Fax:425-339-8707
Is Sole Proprietor?:No
Enumeration Date:2009-01-20
Last Update Date:2009-01-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAHC00155173172V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172V00000XOther Service ProvidersCommunity Health Worker
Provider Identifiers
StateIdentifier IDID TypeIssuer
WAHC00155173OtherHEALTH CARE ASSISTANT