Provider Demographics
NPI:1285656801
Name:KUETTLE, LISA LOUISE (FNP)
Entity Type:Individual
Prefix:MS
First Name:LISA
Middle Name:LOUISE
Last Name:KUETTLE
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:375 NW BEAVER ST STE 101
Mailing Address - Street 2:
Mailing Address - City:PRINEVILLE
Mailing Address - State:OR
Mailing Address - Zip Code:97754-1802
Mailing Address - Country:US
Mailing Address - Phone:541-447-0707
Mailing Address - Fax:541-383-1883
Practice Address - Street 1:1700 SE TEMPEST DR
Practice Address - Street 2:
Practice Address - City:BEND
Practice Address - State:OR
Practice Address - Zip Code:97702-1884
Practice Address - Country:US
Practice Address - Phone:541-323-3854
Practice Address - Fax:541-383-1883
Is Sole Proprietor?:No
Enumeration Date:2006-07-24
Last Update Date:2015-09-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR20055078NP207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR140447Medicaid
OR140447Medicaid
ORH682518OtherPACIFIC SOURCE HEALTH PLA
ORH682423OtherPACIFIC SOURCE HEALTH PLA