Provider Demographics
NPI:1083661169
Name:DORNER, LISA (ARNP)
Entity Type:Individual
Prefix:
First Name:LISA
Middle Name:
Last Name:DORNER
Suffix:
Gender:F
Credentials:ARNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6417 3RD AVE W
Mailing Address - Street 2:
Mailing Address - City:BRADENTON
Mailing Address - State:FL
Mailing Address - Zip Code:34209-2314
Mailing Address - Country:US
Mailing Address - Phone:941-792-4993
Mailing Address - Fax:941-795-2905
Practice Address - Street 1:6417 3RD AVE W
Practice Address - Street 2:
Practice Address - City:BRADENTON
Practice Address - State:FL
Practice Address - Zip Code:34209-2314
Practice Address - Country:US
Practice Address - Phone:941-792-4993
Practice Address - Fax:941-795-2905
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-05-27
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL2861872363LW0102X
FL1609232363LX0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered363LW0102XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerWomen's Health
Not Answered363LX0001XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLP29585Medicare UPIN
Y60022Medicare ID - Type Unspecified