Provider Demographics
NPI:1871088427
Name:VIVANCO, LISA 'LEE' ANN (DNP)
Entity type:Individual
Prefix:
First Name:LISA 'LEE'
Middle Name:ANN
Last Name:VIVANCO
Suffix:
Gender:F
Credentials:DNP
Other - Prefix:
Other - First Name:LISA 'LEE'
Other - Middle Name:ANN
Other - Last Name:MCCAFFREY
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:DNP
Mailing Address - Street 1:3600 LIND AVE SW
Mailing Address - Street 2:SUITE 100 ATTN CREDENTIALING
Mailing Address - City:RENTON
Mailing Address - State:WA
Mailing Address - Zip Code:98057-4970
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:400 S 43RD ST
Practice Address - Street 2:
Practice Address - City:RENTON
Practice Address - State:WA
Practice Address - Zip Code:98055-5714
Practice Address - Country:US
Practice Address - Phone:425-228-3440
Practice Address - Fax:425-656-4214
Is Sole Proprietor?:No
Enumeration Date:2018-06-26
Last Update Date:2021-07-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAAP60865969363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA2104819Medicaid