Provider Demographics
NPI:1902143365
Name:OBORNE, LISA
Entity Type:Individual
Prefix:
First Name:LISA
Middle Name:
Last Name:OBORNE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:22030 SHERMAN WAY
Mailing Address - Street 2:SUITE 101
Mailing Address - City:CANOGA PARK
Mailing Address - State:CA
Mailing Address - Zip Code:91303-1855
Mailing Address - Country:US
Mailing Address - Phone:818-312-9101
Mailing Address - Fax:
Practice Address - Street 1:22030 SHERMAN WAY
Practice Address - Street 2:SUITE 101
Practice Address - City:CANOGA PARK
Practice Address - State:CA
Practice Address - Zip Code:91303-1855
Practice Address - Country:US
Practice Address - Phone:818-312-9101
Practice Address - Fax:818-312-9100
Is Sole Proprietor?:No
Enumeration Date:2013-01-05
Last Update Date:2013-04-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA22184363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health