Provider Demographics
NPI:1225200306
Name:NAZARENUS, LISA (APN)
Entity Type:Individual
Prefix:
First Name:LISA
Middle Name:
Last Name:NAZARENUS
Suffix:
Gender:F
Credentials:APN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:307 S BROADWAY
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:TN
Mailing Address - Zip Code:37148
Mailing Address - Country:US
Mailing Address - Phone:615-325-6755
Mailing Address - Fax:615-325-6936
Practice Address - Street 1:307 S BROADWAY
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:TN
Practice Address - Zip Code:37148
Practice Address - Country:US
Practice Address - Phone:615-325-6755
Practice Address - Fax:615-325-6936
Is Sole Proprietor?:Yes
Enumeration Date:2008-03-28
Last Update Date:2008-03-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNAPN0000013230363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner