Provider Demographics
NPI:1396041885
Name:VANDIEMEN, LISA JILL (FNP)
Entity Type:Individual
Prefix:
First Name:LISA
Middle Name:JILL
Last Name:VANDIEMEN
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:
Other - First Name:LISA
Other - Middle Name:JILL
Other - Last Name:VAN DIEMEN
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:
Mailing Address - Street 1:12197 CROSS FENCE TRL
Mailing Address - Street 2:
Mailing Address - City:TYLER
Mailing Address - State:TX
Mailing Address - Zip Code:75706-4241
Mailing Address - Country:US
Mailing Address - Phone:903-571-4656
Mailing Address - Fax:903-881-1994
Practice Address - Street 1:615 CLINIC DR
Practice Address - Street 2:
Practice Address - City:LONGVIEW
Practice Address - State:TX
Practice Address - Zip Code:75605-5172
Practice Address - Country:US
Practice Address - Phone:903-571-4656
Practice Address - Fax:903-881-1994
Is Sole Proprietor?:Yes
Enumeration Date:2011-02-01
Last Update Date:2023-04-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXAP119904363LP0808X
TX684452363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health