Provider Demographics
NPI:1376730051
Name:BROOME, LISA MARIA (ACNP)
Entity Type:Individual
Prefix:
First Name:LISA
Middle Name:MARIA
Last Name:BROOME
Suffix:
Gender:F
Credentials:ACNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6565 FANNIN ST
Mailing Address - Street 2:SUITE B452
Mailing Address - City:HOUSTON
Mailing Address - State:TX
Mailing Address - Zip Code:77030-2703
Mailing Address - Country:US
Mailing Address - Phone:713-441-3620
Mailing Address - Fax:713-790-2082
Practice Address - Street 1:6565 FANNIN ST
Practice Address - Street 2:SUITE B452
Practice Address - City:HOUSTON
Practice Address - State:TX
Practice Address - Zip Code:77030-2703
Practice Address - Country:US
Practice Address - Phone:713-441-3620
Practice Address - Fax:713-790-2082
Is Sole Proprietor?:No
Enumeration Date:2007-09-26
Last Update Date:2016-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX640579363LA2100X
TXAP115304363LA2100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2100XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAcute Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX8Y3418OtherBLUE CROSS BLUE SHIELD
TXP00628862OtherRAILROAD MEDICARE
TX192155304Medicaid
TX192155301Medicaid
TX8K2108Medicare PIN
TX8Y3418OtherBLUE CROSS BLUE SHIELD