Provider Demographics
NPI:1174854400
Name:TETZLAFF, LISA MARIE (FNP-C)
Entity type:Individual
Prefix:
First Name:LISA
Middle Name:MARIE
Last Name:TETZLAFF
Suffix:
Gender:F
Credentials:FNP-C
Other - Prefix:
Other - First Name:LISA
Other - Middle Name:M
Other - Last Name:DAVIDSON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:FNP-C
Mailing Address - Street 1:9789 W BAIRD ST
Mailing Address - Street 2:
Mailing Address - City:BRIMLEY
Mailing Address - State:MI
Mailing Address - Zip Code:49715-9291
Mailing Address - Country:US
Mailing Address - Phone:906-203-6042
Mailing Address - Fax:
Practice Address - Street 1:700 NEWBERRY AVE
Practice Address - Street 2:
Practice Address - City:NEWBERRY
Practice Address - State:MI
Practice Address - Zip Code:49868-1503
Practice Address - Country:US
Practice Address - Phone:906-293-3226
Practice Address - Fax:877-743-0490
Is Sole Proprietor?:Yes
Enumeration Date:2010-01-27
Last Update Date:2014-07-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DEL1-0037352163WS0200X
MI4704267555363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No163WS0200XNursing Service ProvidersRegistered NurseSchool