Provider Demographics
NPI:1992093819
Name:SABALLY, LISA JANE (CNM)
Entity type:Individual
Prefix:MS
First Name:LISA
Middle Name:JANE
Last Name:SABALLY
Suffix:
Gender:F
Credentials:CNM
Other - Prefix:
Other - First Name:LISA
Other - Middle Name:
Other - Last Name:MALMQUIST
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:CNM
Mailing Address - Street 1:PO BOX 3158
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97208-3158
Mailing Address - Country:US
Mailing Address - Phone:503-215-6494
Mailing Address - Fax:
Practice Address - Street 1:9135 SW BARNES RD STE 761
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97225-6777
Practice Address - Country:US
Practice Address - Phone:503-216-2602
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-07-12
Last Update Date:2024-01-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR201350008NP367A00000X, 367A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367A00000XPhysician Assistants & Advanced Practice Nursing ProvidersAdvanced Practice Midwife
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR500656974Medicaid
OR500656974Medicaid