Provider Demographics
NPI:1043458532
Name:GROSS, LISA NICOLE (ATC)
Entity Type:Individual
Prefix:MISS
First Name:LISA
Middle Name:NICOLE
Last Name:GROSS
Suffix:
Gender:F
Credentials:ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4410 PENNSYLVANIA AVE APT 4
Mailing Address - Street 2:
Mailing Address - City:KANSAS CITY
Mailing Address - State:MO
Mailing Address - Zip Code:64111-3323
Mailing Address - Country:US
Mailing Address - Phone:785-766-5412
Mailing Address - Fax:
Practice Address - Street 1:4410 PENNSYLVANIA AVE APT 4
Practice Address - Street 2:
Practice Address - City:KANSAS CITY
Practice Address - State:MO
Practice Address - Zip Code:64111-3323
Practice Address - Country:US
Practice Address - Phone:785-766-5412
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-01-22
Last Update Date:2009-01-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS24-006422255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer
Provider Identifiers
StateIdentifier IDID TypeIssuer
KS24-00642OtherKANSAS STATE BOARD OF HEALING ARTS