Provider Demographics
NPI:1083078349
Name:LAND, LISA MARIE (NP-C, ACNPC-AG)
Entity Type:Individual
Prefix:MRS
First Name:LISA
Middle Name:MARIE
Last Name:LAND
Suffix:
Gender:F
Credentials:NP-C, ACNPC-AG
Other - Prefix:MS
Other - First Name:LISA
Other - Middle Name:MARIE
Other - Last Name:SIMES
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:1739 E BEVERLY AVE
Mailing Address - Street 2:SUITE 203
Mailing Address - City:KINGMAN
Mailing Address - State:AZ
Mailing Address - Zip Code:86409-3593
Mailing Address - Country:US
Mailing Address - Phone:928-757-3133
Mailing Address - Fax:
Practice Address - Street 1:1739 E BEVERLY AVE
Practice Address - Street 2:SUITE 203
Practice Address - City:KINGMAN
Practice Address - State:AZ
Practice Address - Zip Code:86409-3593
Practice Address - Country:US
Practice Address - Phone:928-757-3133
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-04-12
Last Update Date:2023-01-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZAP8621363L00000X, 363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner