Provider Demographics
NPI:1295599702
Name:ROUSSEAU, LISA ANN
Entity type:Individual
Prefix:
First Name:LISA
Middle Name:ANN
Last Name:ROUSSEAU
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:LISA
Other - Middle Name:ANN
Other - Last Name:LOPEZ
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1275 8TH ST
Mailing Address - Street 2:
Mailing Address - City:ARCATA
Mailing Address - State:CA
Mailing Address - Zip Code:95521-5770
Mailing Address - Country:US
Mailing Address - Phone:707-826-8633
Mailing Address - Fax:707-826-6838
Practice Address - Street 1:3750 ROHNERVILLE RD
Practice Address - Street 2:
Practice Address - City:FORTUNA
Practice Address - State:CA
Practice Address - Zip Code:95540-3118
Practice Address - Country:US
Practice Address - Phone:707-725-6101
Practice Address - Fax:707-725-2978
Is Sole Proprietor?:No
Enumeration Date:2024-02-06
Last Update Date:2024-02-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA95258711163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse