Provider Demographics
NPI:1306223482
Name:LIS, GINA
Entity Type:Individual
Prefix:
First Name:GINA
Middle Name:
Last Name:LIS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3775 BUSHMAN LAKE LN
Mailing Address - Street 2:
Mailing Address - City:ORTONVILLE
Mailing Address - State:MI
Mailing Address - Zip Code:48462-9240
Mailing Address - Country:US
Mailing Address - Phone:248-310-7133
Mailing Address - Fax:
Practice Address - Street 1:3775 BUSHMAN LAKE LN
Practice Address - Street 2:
Practice Address - City:ORTONVILLE
Practice Address - State:MI
Practice Address - Zip Code:48462-9240
Practice Address - Country:US
Practice Address - Phone:248-310-7133
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-04-28
Last Update Date:2015-04-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4704157099163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse