Provider Demographics
NPI:1396951901
Name:FEDDERSEN, LISA ANN (RN)
Entity type:Individual
Prefix:
First Name:LISA
Middle Name:ANN
Last Name:FEDDERSEN
Suffix:
Gender:F
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:16824 N 51ST ST
Mailing Address - Street 2:
Mailing Address - City:SCOTTSDALE
Mailing Address - State:AZ
Mailing Address - Zip Code:85254-1065
Mailing Address - Country:US
Mailing Address - Phone:602-692-2722
Mailing Address - Fax:480-889-1574
Practice Address - Street 1:1450 S DOBSON RD STE B324
Practice Address - Street 2:
Practice Address - City:MESA
Practice Address - State:AZ
Practice Address - Zip Code:85202-4712
Practice Address - Country:US
Practice Address - Phone:480-889-1573
Practice Address - Fax:480-889-1574
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-14
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZRN133209163WA2000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WA2000XNursing Service ProvidersRegistered NurseAdministrator