Provider Demographics
NPI:1164400941
Name:MCLOUGHLIN, LISA PATRICE (ARNP)
Entity Type:Individual
Prefix:MS
First Name:LISA
Middle Name:PATRICE
Last Name:MCLOUGHLIN
Suffix:
Gender:F
Credentials:ARNP
Other - Prefix:
Other - First Name:LISA
Other - Middle Name:PATRICE
Other - Last Name:SULLIVAN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:NP
Mailing Address - Street 1:2812 WOODMERE DR
Mailing Address - Street 2:
Mailing Address - City:PANAMA CITY
Mailing Address - State:FL
Mailing Address - Zip Code:32405-4384
Mailing Address - Country:US
Mailing Address - Phone:401-575-9848
Mailing Address - Fax:
Practice Address - Street 1:2812 WOODMERE DR
Practice Address - Street 2:
Practice Address - City:PANAMA CITY
Practice Address - State:FL
Practice Address - Zip Code:32405-4384
Practice Address - Country:US
Practice Address - Phone:401-575-9848
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-01-03
Last Update Date:2010-07-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN71002026A363LF0000X
FLARNP9270099363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
INQ51812Medicare UPIN
IN940870TTTMedicare ID - Type Unspecified