Provider Demographics
NPI:1134009095
Name:AN, LISA
Entity type:Individual
Prefix:
First Name:LISA
Middle Name:
Last Name:AN
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 1:402 APPLE CREEK LN
Mailing Address - Street 2:
Mailing Address - City:SANTA ROSA
Mailing Address - State:CA
Mailing Address - Zip Code:95401-6190
Mailing Address - Country:US
Mailing Address - Phone:916-305-0574
Mailing Address - Fax:
Practice Address - Street 1:1000 YULUPA AVE
Practice Address - Street 2:
Practice Address - City:SANTA ROSA
Practice Address - State:CA
Practice Address - Zip Code:95405-7020
Practice Address - Country:US
Practice Address - Phone:916-305-0574
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-09-03
Last Update Date:2025-09-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA95364553163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes163W00000XNursing Service ProvidersRegistered NurseGroup - Single Specialty