Provider Demographics
NPI:1053562637
Name:JERICHO, LISA ANN (CRNA)
Entity type:Individual
Prefix:MRS
First Name:LISA
Middle Name:ANN
Last Name:JERICHO
Suffix:
Gender:F
Credentials:CRNA
Other - Prefix:
Other - First Name:LISA
Other - Middle Name:ANN
Other - Last Name:BLOOD
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:CRNA
Mailing Address - Street 1:2450 W HUNTING PARK AVE
Mailing Address - Street 2:
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19129-1302
Mailing Address - Country:US
Mailing Address - Phone:215-707-3326
Mailing Address - Fax:215-707-8028
Practice Address - Street 1:333 COTTMAN AVE
Practice Address - Street 2:
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19111-2497
Practice Address - Country:US
Practice Address - Phone:215-707-3326
Practice Address - Fax:215-707-8028
Is Sole Proprietor?:No
Enumeration Date:2008-10-01
Last Update Date:2018-05-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PARN329971L367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered