Provider Demographics
NPI:1144092941
Name:ATWATER, LISA ANN
Entity type:Individual
Prefix:
First Name:LISA
Middle Name:ANN
Last Name:ATWATER
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 1:209 AUSTINE DR
Mailing Address - Street 2:
Mailing Address - City:BRATTLEBORO
Mailing Address - State:VT
Mailing Address - Zip Code:05301-7223
Mailing Address - Country:US
Mailing Address - Phone:802-490-9619
Mailing Address - Fax:802-258-2413
Practice Address - Street 1:209 AUSTINE DR
Practice Address - Street 2:
Practice Address - City:BRATTLEBORO
Practice Address - State:VT
Practice Address - Zip Code:05301-7223
Practice Address - Country:US
Practice Address - Phone:802-490-9619
Practice Address - Fax:802-258-2413
Is Sole Proprietor?:Yes
Enumeration Date:2023-10-25
Last Update Date:2023-10-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VT172V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172V00000XOther Service ProvidersCommunity Health Worker