Provider Demographics
NPI:1043375785
Name:HINEMAN, LISA DIANNE (NP)
Entity Type:Individual
Prefix:MRS
First Name:LISA
Middle Name:DIANNE
Last Name:HINEMAN
Suffix:
Gender:F
Credentials:NP
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Other - First Name:
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Other - Credentials:
Mailing Address - Street 1:541 W COLORADO ST STE 205
Mailing Address - Street 2:
Mailing Address - City:GLENDALE
Mailing Address - State:CA
Mailing Address - Zip Code:91204-3640
Mailing Address - Country:US
Mailing Address - Phone:323-254-0046
Mailing Address - Fax:323-488-9782
Practice Address - Street 1:1245 WILSHIRE BLVD STE 303
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90017-4803
Practice Address - Country:US
Practice Address - Phone:213-977-1214
Practice Address - Fax:213-482-8868
Is Sole Proprietor?:No
Enumeration Date:2006-12-22
Last Update Date:2019-01-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CANPF 13556363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAP93008Medicare UPIN