Basic Information
| Provider Information | |||||||||
| NPI: | 1629228929 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | GATES | ||||||||
| FirstName: | LISA | ||||||||
| MiddleName: | A | ||||||||
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| Credential: | R.N. BSN | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3033 KETTERING BLVD STE 100 | ||||||||
| Address2: | |||||||||
| City: | MORAINE | ||||||||
| State: | OH | ||||||||
| PostalCode: | 454391948 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9372932133 | ||||||||
| FaxNumber: | 8552522435 | ||||||||
| Practice Location | |||||||||
| Address1: | 3033 KETTERING BLVD STE 100 | ||||||||
| Address2: | |||||||||
| City: | MORAINE | ||||||||
| State: | OH | ||||||||
| PostalCode: | 45439 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9372932133 | ||||||||
| FaxNumber: | 8552522435 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/23/2008 | ||||||||
| LastUpdateDate: | 04/21/2020 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 04/21/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 163W00000X | RN 207875 | OH | N | Nursing Service Providers | Registered Nurse | 363LF0000X | APRN.CNP.024014 | OH | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family |
No ID Information.