Provider Demographics
NPI:1356094148
Name:MILLER, LISA MARIE (CNP, PMHNP-BC)
Entity Type:Individual
Prefix:
First Name:LISA
Middle Name:MARIE
Last Name:MILLER
Suffix:
Gender:F
Credentials:CNP, PMHNP-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:415 N 3RD AVE STE B
Mailing Address - Street 2:
Mailing Address - City:POCATELLO
Mailing Address - State:ID
Mailing Address - Zip Code:83201-6306
Mailing Address - Country:US
Mailing Address - Phone:208-646-4165
Mailing Address - Fax:
Practice Address - Street 1:415 N 3RD AVE STE B
Practice Address - Street 2:
Practice Address - City:POCATELLO
Practice Address - State:ID
Practice Address - Zip Code:83201-6306
Practice Address - Country:US
Practice Address - Phone:208-646-4165
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-02-01
Last Update Date:2023-08-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ID70995363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health