Provider Demographics
NPI:1376239665
Name:MEMMEL, LISA
Entity Type:Individual
Prefix:
First Name:LISA
Middle Name:
Last Name:MEMMEL
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:PO BOX 58659
Mailing Address - Street 2:
Mailing Address - City:FAIRBANKS
Mailing Address - State:AK
Mailing Address - Zip Code:99711-0659
Mailing Address - Country:US
Mailing Address - Phone:907-460-0143
Mailing Address - Fax:
Practice Address - Street 1:1096 COPPER ST
Practice Address - Street 2:
Practice Address - City:NORTH POLE
Practice Address - State:AK
Practice Address - Zip Code:99705-5775
Practice Address - Country:US
Practice Address - Phone:907-460-0143
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-04-11
Last Update Date:2023-04-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AK22778246Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes246Z00000XTechnologists, Technicians & Other Technical Service ProvidersSpecialist/Technologist, Other