Provider Demographics
NPI:1356017446
Name:PATRICK, LISA
Entity Type:Individual
Prefix:
First Name:LISA
Middle Name:
Last Name:PATRICK
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 1:16533 TIMBERLANE DR
Mailing Address - Street 2:
Mailing Address - City:OMAHA
Mailing Address - State:NE
Mailing Address - Zip Code:68136-3077
Mailing Address - Country:US
Mailing Address - Phone:308-940-0132
Mailing Address - Fax:
Practice Address - Street 1:515 N 162ND AVE STE 102
Practice Address - Street 2:
Practice Address - City:OMAHA
Practice Address - State:NE
Practice Address - Zip Code:68118-2540
Practice Address - Country:US
Practice Address - Phone:402-397-6600
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-08-18
Last Update Date:2021-08-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE68469163WW0101X
NE113700363LW0102X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LW0102XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerWomen's Health
No163WW0101XNursing Service ProvidersRegistered NurseWomen's Health Care, Ambulatory