Provider Demographics
NPI:1093893927
Name:LIPPERT, JOHANNA C (NP)
Entity Type:Individual
Prefix:
First Name:JOHANNA
Middle Name:C
Last Name:LIPPERT
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3450 N 3RD ST
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85012-2331
Mailing Address - Country:US
Mailing Address - Phone:602-265-8338
Mailing Address - Fax:602-265-8574
Practice Address - Street 1:10220 N 31ST AVE
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85051-9562
Practice Address - Country:US
Practice Address - Phone:602-997-2233
Practice Address - Fax:602-997-2667
Is Sole Proprietor?:No
Enumeration Date:2006-11-01
Last Update Date:2012-02-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZRN062405363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ846363Medicaid
AZ846363Medicaid
Z103671Medicare PIN