Provider Demographics
NPI:1992970552
Name:SANTO DOMINGO, LISA LINN (CRNP-PEDIATRICS)
Entity type:Individual
Prefix:MRS
First Name:LISA
Middle Name:LINN
Last Name:SANTO DOMINGO
Suffix:
Gender:F
Credentials:CRNP-PEDIATRICS
Other - Prefix:
Other - First Name:LISA
Other - Middle Name:LINN
Other - Last Name:SEAMAN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:CRNP-PEDIATRICS
Mailing Address - Street 1:600 N WOLFE ST
Mailing Address - Street 2:BRADY 320
Mailing Address - City:BALTIMORE
Mailing Address - State:MD
Mailing Address - Zip Code:21287-0005
Mailing Address - Country:US
Mailing Address - Phone:410-955-8769
Mailing Address - Fax:410-955-1464
Practice Address - Street 1:600 N WOLFE ST
Practice Address - Street 2:BRADY 320
Practice Address - City:BALTIMORE
Practice Address - State:MD
Practice Address - Zip Code:21287-0005
Practice Address - Country:US
Practice Address - Phone:410-955-8769
Practice Address - Fax:410-955-1464
Is Sole Proprietor?:No
Enumeration Date:2008-04-24
Last Update Date:2012-08-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDR175012363LP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD027626000Medicaid
MD169370ZAK7Medicare PIN