Provider Demographics
NPI:1003181132
Name:OETJEN, LISA JOI (APRN, FNP-C)
Entity Type:Individual
Prefix:MRS
First Name:LISA
Middle Name:JOI
Last Name:OETJEN
Suffix:
Gender:F
Credentials:APRN, FNP-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:510 LINCOLN DR
Mailing Address - Street 2:
Mailing Address - City:HERRIN
Mailing Address - State:IL
Mailing Address - Zip Code:62948-6334
Mailing Address - Country:US
Mailing Address - Phone:618-997-6800
Mailing Address - Fax:618-997-1187
Practice Address - Street 1:4787 ALBEN BARKLEY DR
Practice Address - Street 2:
Practice Address - City:PADUCAH
Practice Address - State:KY
Practice Address - Zip Code:42001-6789
Practice Address - Country:US
Practice Address - Phone:270-442-9461
Practice Address - Fax:270-441-0079
Is Sole Proprietor?:No
Enumeration Date:2012-03-22
Last Update Date:2017-03-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY3007393363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY000000811812OtherANTHEM
KY7100238100Medicaid
KY000000811812OtherANTHEM