Provider Demographics
NPI:1407332414
Name:SCANLON, LISA ANNE (ACNPC-AG)
Entity Type:Individual
Prefix:
First Name:LISA
Middle Name:ANNE
Last Name:SCANLON
Suffix:
Gender:F
Credentials:ACNPC-AG
Other - Prefix:
Other - First Name:LISA
Other - Middle Name:ANNE
Other - Last Name:REDDMANN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:313 THREE MEADOWS CT
Mailing Address - Street 2:
Mailing Address - City:PERRYSBURG
Mailing Address - State:OH
Mailing Address - Zip Code:43551-5514
Mailing Address - Country:US
Mailing Address - Phone:419-329-8264
Mailing Address - Fax:
Practice Address - Street 1:524 W HIGH ST
Practice Address - Street 2:
Practice Address - City:BRYAN
Practice Address - State:OH
Practice Address - Zip Code:43506-1618
Practice Address - Country:US
Practice Address - Phone:419-636-9800
Practice Address - Fax:419-636-0451
Is Sole Proprietor?:Yes
Enumeration Date:2018-07-12
Last Update Date:2020-07-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH022921363LA2100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2100XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAcute Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0342434Medicaid