Provider Demographics
NPI:1013008390
Name:BORK, LISA K (APN)
Entity Type:Individual
Prefix:MRS
First Name:LISA
Middle Name:K
Last Name:BORK
Suffix:
Gender:F
Credentials:APN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:NEMOURS CHILDRENS CLINIC
Mailing Address - Street 2:P.O. BOX 404112
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30384-0001
Mailing Address - Country:US
Mailing Address - Phone:904-390-3610
Mailing Address - Fax:904-288-5890
Practice Address - Street 1:1665 SW HIGHWAY 484 STE 105
Practice Address - Street 2:
Practice Address - City:OCALA
Practice Address - State:FL
Practice Address - Zip Code:34473-1996
Practice Address - Country:US
Practice Address - Phone:352-693-5900
Practice Address - Fax:352-693-5805
Is Sole Proprietor?:No
Enumeration Date:2006-09-28
Last Update Date:2021-06-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DEL10018050363LP0200X
FL9466961363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No363LP0200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD4039858Medicaid
NJ0023825Medicaid
Q13129Medicare UPIN
013955T34Medicare PIN