Individual
LISA BALLANTYNE
Active
Sole proprietor
No
Provider details
NPI number
Gender
F
Contact information
Practice address
2245 CHALLENGER WAY, SANTA ROSA, CA 95407-5418
(707) 565-4970
Mailing address
2245 CHALLENGER WAY, SANTA ROSA, CA 95407-5418
Taxonomy
Speciality
Code
Description
License number
State
163WP0808X
Psychiatric/Mental Health Registered Nurse
Primary
612777
CA
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
612777
MEDI-CAL
CA
Enumeration date
02/26/2019
Last updated
02/26/2019
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