Provider Demographics
NPI:1861538597
Name:FERNANDEZ, LISA M (PT)
Entity type:Individual
Prefix:MS
First Name:LISA
Middle Name:M
Last Name:FERNANDEZ
Suffix:
Gender:F
Credentials:PT
Other - Prefix:MS
Other - First Name:LISA
Other - Middle Name:M
Other - Last Name:FERNANDEZ
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:PT
Mailing Address - Street 1:1375 S COTTERELL WAY
Mailing Address - Street 2:
Mailing Address - City:BOISE
Mailing Address - State:ID
Mailing Address - Zip Code:83709-1504
Mailing Address - Country:US
Mailing Address - Phone:208-378-9194
Mailing Address - Fax:
Practice Address - Street 1:1375 S COTTERELL WAY
Practice Address - Street 2:
Practice Address - City:BOISE
Practice Address - State:ID
Practice Address - Zip Code:83709-1504
Practice Address - Country:US
Practice Address - Phone:208-378-9194
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-29
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDRPT-514225100000X
VT040-0001077225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist