Individual
LISA DAWN THEOBALD
Active
Sole proprietor
Yes
Provider details
NPI number
Gender
F
Credential
PMHNP
Contact information
Practice address
2264 MCGILCHRIST ST SE STE 100, SALEM, OR 97302-1008
(503) 930-1812
Mailing address
2264 MCGILCHRIST ST SE STE 100, SALEM, OR 97302-1008
Taxonomy
Speciality
Code
Description
License number
State
363LP0808X
Psychiatric/Mental Health Nurse Practitioner
Primary
10006245
OR
Other
Enumeration date
06/05/2023
Last updated
03/13/2024
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