Basic Information
| Provider Information | |||||||||
| NPI: | 1831663426 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | POWELL | ||||||||
| FirstName: | LISA | ||||||||
| MiddleName: | LEVIDA | ||||||||
| NamePrefix: | MS. | ||||||||
| NameSuffix: | |||||||||
| Credential: | LVN | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2860 NIOBRARA AVE | ||||||||
| Address2: | |||||||||
| City: | STOCKTON | ||||||||
| State: | CA | ||||||||
| PostalCode: | 952066418 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5102533832 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 1133 COLOMA WAY STE C | ||||||||
| Address2: | |||||||||
| City: | ROSEVILLE | ||||||||
| State: | CA | ||||||||
| PostalCode: | 956614480 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9167746647 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/16/2019 | ||||||||
| LastUpdateDate: | 01/16/2019 | ||||||||
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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 | 164X00000X | 235848 | CA | Y | Nursing Service Providers | Licensed Vocational Nurse |
ID Information
| ID | Type | State | Issuer | Description | 10 | 01 | CA | METHADONE CLINIC | OTHER |