Provider Demographics
NPI:1366877433
Name:VELLINGA, LISA CHRISTINA (RN, CRNA)
Entity type:Individual
Prefix:
First Name:LISA
Middle Name:CHRISTINA
Last Name:VELLINGA
Suffix:
Gender:F
Credentials:RN, CRNA
Other - Prefix:
Other - First Name:LISA
Other - Middle Name:CHRISTINA
Other - Last Name:BOROM
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 1547
Mailing Address - Street 2:
Mailing Address - City:SEDALIA
Mailing Address - State:MO
Mailing Address - Zip Code:65302-1547
Mailing Address - Country:US
Mailing Address - Phone:660-826-5960
Mailing Address - Fax:
Practice Address - Street 1:1299 BERTHA HOWE AVE
Practice Address - Street 2:
Practice Address - City:MESQUITE
Practice Address - State:NV
Practice Address - Zip Code:89027-7500
Practice Address - Country:US
Practice Address - Phone:775-336-7438
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-09-09
Last Update Date:2022-03-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN28272044A367500000X
NVCRNA000483367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
NVV111547Medicare PIN