Basic Information
| Provider Information | |||||||||
| NPI: | 1346560588 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | DAVIS | ||||||||
| FirstName: | LISA | ||||||||
| MiddleName: | SUSAN | ||||||||
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| Credential: | CRNA, APRN | ||||||||
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| Mailing Information | |||||||||
| Address1: | 23 MOUNTAINSIDE DR | ||||||||
| Address2: | |||||||||
| City: | NEWBURY | ||||||||
| State: | NH | ||||||||
| PostalCode: | 032555205 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6037276253 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 35 MILES ST | ||||||||
| Address2: | |||||||||
| City: | DAMARISCOTTA | ||||||||
| State: | ME | ||||||||
| PostalCode: | 045434047 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2075631234 | ||||||||
| FaxNumber: | 6032282113 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/10/2010 | ||||||||
| LastUpdateDate: | 01/15/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 01/15/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 367500000X | RNA173018 | ME | N | Physician Assistants & Advanced Practice Nursing Providers | Nurse Anesthetist, Certified Registered | 367500000X | 06244323 | NH | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Anesthetist, Certified Registered | 367500000X | RN529981L | PA | N | Physician Assistants & Advanced Practice Nursing Providers | Nurse Anesthetist, Certified Registered |
ID Information
| ID | Type | State | Issuer | Description | 3096163 | 05 | NH | MEDICAID |