Provider Demographics
NPI:1376209155
Name:WILSON, LISA D (RN)
Entity Type:Individual
Prefix:
First Name:LISA
Middle Name:D
Last Name:WILSON
Suffix:
Gender:F
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:764 JEFFERSON ST
Mailing Address - Street 2:
Mailing Address - City:MOUNT MORRIS
Mailing Address - State:MI
Mailing Address - Zip Code:48458-3215
Mailing Address - Country:US
Mailing Address - Phone:810-874-9298
Mailing Address - Fax:
Practice Address - Street 1:8360 S SAGINAW ST
Practice Address - Street 2:
Practice Address - City:GRAND BLANC
Practice Address - State:MI
Practice Address - Zip Code:48439-1850
Practice Address - Country:US
Practice Address - Phone:810-694-2500
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-11-16
Last Update Date:2021-11-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4704364834163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse