Provider Demographics
NPI:1083037493
Name:UPSHUR, LISA MARIE-MCCLEARY (RN, ACNP-BC)
Entity Type:Individual
Prefix:MRS
First Name:LISA
Middle Name:MARIE-MCCLEARY
Last Name:UPSHUR
Suffix:
Gender:F
Credentials:RN, ACNP-BC
Other - Prefix:MISS
Other - First Name:LISA
Other - Middle Name:MARIE
Other - Last Name:MCCLEARY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:RN
Mailing Address - Street 1:36475 FIVE MILE RD
Mailing Address - Street 2:
Mailing Address - City:LIVONIA
Mailing Address - State:MI
Mailing Address - Zip Code:48154-1971
Mailing Address - Country:US
Mailing Address - Phone:734-655-3243
Mailing Address - Fax:734-655-3219
Practice Address - Street 1:36475 FIVE MILE RD
Practice Address - Street 2:
Practice Address - City:LIVONIA
Practice Address - State:MI
Practice Address - Zip Code:48154-1971
Practice Address - Country:US
Practice Address - Phone:734-655-3243
Practice Address - Fax:734-655-3219
Is Sole Proprietor?:No
Enumeration Date:2014-01-22
Last Update Date:2014-01-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4704195671363LA2100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2100XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAcute Care