Provider Demographics
NPI:1376830414
Name:MICONI-CORREA, LISA (FNP)
Entity Type:Individual
Prefix:
First Name:LISA
Middle Name:
Last Name:MICONI-CORREA
Suffix:
Gender:F
Credentials:FNP
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 5546
Mailing Address - Street 2:
Mailing Address - City:DENVER
Mailing Address - State:CO
Mailing Address - Zip Code:80217-5546
Mailing Address - Country:US
Mailing Address - Phone:801-479-7771
Mailing Address - Fax:801-479-7795
Practice Address - Street 1:5740 CRESTWOOD DR
Practice Address - Street 2:
Practice Address - City:OGDEN
Practice Address - State:UT
Practice Address - Zip Code:84405-4869
Practice Address - Country:US
Practice Address - Phone:801-479-7771
Practice Address - Fax:801-479-7795
Is Sole Proprietor?:No
Enumeration Date:2011-07-08
Last Update Date:2017-01-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT200854-4408363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
UTU000095996Medicare PIN