Basic Information
| Provider Information | |||||||||
| NPI: | 1205930831 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | STURDEVANT | ||||||||
| FirstName: | LISSA | ||||||||
| MiddleName: | WYNNE | ||||||||
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| Credential: | NP | ||||||||
| OtherOrganizationName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 995 POTRERO AVE | ||||||||
| Address2: | WARD 86 | ||||||||
| City: | SAN FRANCISCO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 941102859 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4154764082 | ||||||||
| FaxNumber: | 4154768881 | ||||||||
| Practice Location | |||||||||
| Address1: | 995 POTRERO AVE | ||||||||
| Address2: | WARD 86 | ||||||||
| City: | SAN FRANCISCO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 941102859 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4154764082 | ||||||||
| FaxNumber: | 4154768881 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/12/2006 | ||||||||
| LastUpdateDate: | 01/07/2008 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363L00000X | NP15915 | CA | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner |
No ID Information.