Provider Demographics
NPI:1437248705
Name:COLWICK, LISA E (FNP)
Entity Type:Individual
Prefix:
First Name:LISA
Middle Name:E
Last Name:COLWICK
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 1:1017 N MAIN ST
Mailing Address - Street 2:
Mailing Address - City:SIKESTON
Mailing Address - State:MO
Mailing Address - Zip Code:63801-5043
Mailing Address - Country:US
Mailing Address - Phone:573-472-6030
Mailing Address - Fax:573-472-6029
Practice Address - Street 1:1017 N MAIN ST
Practice Address - Street 2:
Practice Address - City:SIKESTON
Practice Address - State:MO
Practice Address - Zip Code:63801-5043
Practice Address - Country:US
Practice Address - Phone:573-472-6030
Practice Address - Fax:573-472-6029
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-12
Last Update Date:2013-08-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO081070363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO428896013Medicaid
MO428896013Medicaid