Provider Demographics
NPI:1346510252
Name:WOODRUFF, LISA RAE (ANP)
Entity Type:Individual
Prefix:
First Name:LISA
Middle Name:RAE
Last Name:WOODRUFF
Suffix:
Gender:F
Credentials:ANP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:28284 62ND AVE
Mailing Address - Street 2:
Mailing Address - City:LAWTON
Mailing Address - State:MI
Mailing Address - Zip Code:49065-5613
Mailing Address - Country:US
Mailing Address - Phone:269-547-7630
Mailing Address - Fax:269-225-0607
Practice Address - Street 1:200 MICHIGAN AVE W STE 103
Practice Address - Street 2:
Practice Address - City:BATTLE CREEK
Practice Address - State:MI
Practice Address - Zip Code:49017-3632
Practice Address - Country:US
Practice Address - Phone:269-598-7488
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-01-09
Last Update Date:2023-04-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4704253495363LA2200X
AK185256363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
No363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI1801818752OtherBCBSM - BRONSON LAKEVIEW BEHAVIORAL MEDICINE
MI1346510252Medicaid
MI1801818752OtherBCBSM - BRONSON LAKEVIEW BEHAVIORAL MEDICINE