Provider Demographics
NPI:1902101470
Name:COTTER, LISA MARIE (CRNA)
Entity Type:Individual
Prefix:
First Name:LISA
Middle Name:MARIE
Last Name:COTTER
Suffix:
Gender:F
Credentials:CRNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2041 LAKE DR
Mailing Address - Street 2:
Mailing Address - City:WINTER PARK
Mailing Address - State:FL
Mailing Address - Zip Code:32789-2837
Mailing Address - Country:US
Mailing Address - Phone:513-464-0767
Mailing Address - Fax:
Practice Address - Street 1:3535 SOUTHERN BLVD
Practice Address - Street 2:
Practice Address - City:KETTERING
Practice Address - State:OH
Practice Address - Zip Code:45429-1221
Practice Address - Country:US
Practice Address - Phone:937-293-8228
Practice Address - Fax:937-293-8229
Is Sole Proprietor?:No
Enumeration Date:2011-01-14
Last Update Date:2021-04-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHRN.254792367500000X
OHAPRN.CRNA.121118367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered