Provider Demographics
NPI:1851630040
Name:BLACKETTER, LISA DIANE (CRNA)
Entity type:Individual
Prefix:
First Name:LISA
Middle Name:DIANE
Last Name:BLACKETTER
Suffix:
Gender:F
Credentials:CRNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:2701 HOSPITAL DR
Mailing Address - Street 2:
Mailing Address - City:VICTORIA
Mailing Address - State:TX
Mailing Address - Zip Code:77901-5749
Mailing Address - Country:US
Mailing Address - Phone:361-573-9181
Mailing Address - Fax:361-582-5743
Practice Address - Street 1:2701 HOSPITAL DR
Practice Address - Street 2:
Practice Address - City:VICTORIA
Practice Address - State:TX
Practice Address - Zip Code:77901-5749
Practice Address - Country:US
Practice Address - Phone:361-573-9181
Practice Address - Fax:361-582-5743
Is Sole Proprietor?:No
Enumeration Date:2013-02-07
Last Update Date:2024-10-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL209010216367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered