Provider Demographics
NPI:1447359955
Name:DURETTE, LISA ANN (MD)
Entity type:Individual
Prefix:DR
First Name:LISA
Middle Name:ANN
Last Name:DURETTE
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
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Mailing Address - Street 1:3016 W CHARLESTON BLVD
Mailing Address - Street 2:STE 100
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89102-1973
Mailing Address - Country:US
Mailing Address - Phone:702-780-7118
Mailing Address - Fax:
Practice Address - Street 1:6375 W CHARLESTON BLVD STE A-100
Practice Address - Street 2:
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89146-1139
Practice Address - Country:US
Practice Address - Phone:702-253-0818
Practice Address - Fax:702-253-9625
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-21
Last Update Date:2020-06-02
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
NV108692084P0804X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0804XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyChild & Adolescent Psychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
NV100504475Medicaid
NV100504475Medicaid
40114Medicare ID - Type Unspecified