Provider Demographics
NPI:1114188604
Name:POLHAMUS, LISA MARIE (NNP)
Entity Type:Individual
Prefix:MS
First Name:LISA
Middle Name:MARIE
Last Name:POLHAMUS
Suffix:
Gender:F
Credentials:NNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:501 6TH AVE S
Mailing Address - Street 2:
Mailing Address - City:ST PETERSBURG
Mailing Address - State:FL
Mailing Address - Zip Code:33701-4634
Mailing Address - Country:US
Mailing Address - Phone:727-767-4313
Mailing Address - Fax:727-767-4391
Practice Address - Street 1:501 6TH AVE S
Practice Address - Street 2:
Practice Address - City:ST PETERSBURG
Practice Address - State:FL
Practice Address - Zip Code:33701
Practice Address - Country:US
Practice Address - Phone:727-767-4313
Practice Address - Fax:727-767-4391
Is Sole Proprietor?:Yes
Enumeration Date:2008-06-18
Last Update Date:2018-06-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLARNP9481675363LN0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LN0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerNeonatal
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL024415700Medicaid