Provider Demographics
NPI:1205184553
Name:ANDERSON, LISA ANNETTE (LPN)
Entity Type:Individual
Prefix:MRS
First Name:LISA
Middle Name:ANNETTE
Last Name:ANDERSON
Suffix:
Gender:F
Credentials:LPN
Other - Prefix:MS
Other - First Name:LISA
Other - Middle Name:ANNETTE
Other - Last Name:EBERSOLE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:LPN
Mailing Address - Street 1:2422 N GRANDVIEW BLVD
Mailing Address - Street 2:
Mailing Address - City:WAUKESHA
Mailing Address - State:WI
Mailing Address - Zip Code:53188-6105
Mailing Address - Country:US
Mailing Address - Phone:262-549-6600
Mailing Address - Fax:262-549-6698
Practice Address - Street 1:2422 N GRANDVIEW BLVD
Practice Address - Street 2:
Practice Address - City:WAUKESHA
Practice Address - State:WI
Practice Address - Zip Code:53188-6105
Practice Address - Country:US
Practice Address - Phone:262-549-6600
Practice Address - Fax:262-549-6698
Is Sole Proprietor?:Yes
Enumeration Date:2012-08-16
Last Update Date:2013-08-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI312381-31164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse