Provider Demographics
NPI:1902945686
Name:DURHAM, LISA (LVN)
Entity type:Individual
Prefix:
First Name:LISA
Middle Name:
Last Name:DURHAM
Suffix:
Gender:F
Credentials:LVN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:200 E ALESSANDRO BLVD
Mailing Address - Street 2:APT 67
Mailing Address - City:RIVERSIDE
Mailing Address - State:CA
Mailing Address - Zip Code:92508-6180
Mailing Address - Country:US
Mailing Address - Phone:951-789-0838
Mailing Address - Fax:
Practice Address - Street 1:1700 IOWA AVE
Practice Address - Street 2:SUITE 230
Practice Address - City:RIVERSIDE
Practice Address - State:CA
Practice Address - Zip Code:92507-2420
Practice Address - Country:US
Practice Address - Phone:951-369-8604
Practice Address - Fax:951-715-4594
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-06
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAVN207886164X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164X00000XNursing Service ProvidersLicensed Vocational Nurse