Provider Demographics
NPI:1467231779
Name:ENDEBROCK, LISA (RN)
Entity Type:Individual
Prefix:
First Name:LISA
Middle Name:
Last Name:ENDEBROCK
Suffix:
Gender:F
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7 S WING ST #10 ALTAMONT CUSD
Mailing Address - Street 2:
Mailing Address - City:ALTAMONT
Mailing Address - State:IL
Mailing Address - Zip Code:62411-1265
Mailing Address - Country:US
Mailing Address - Phone:618-483-6195
Mailing Address - Fax:618-483-6303
Practice Address - Street 1:7 S WING ST #10 ALTAMONT CUSD
Practice Address - Street 2:
Practice Address - City:ALTAMONT
Practice Address - State:IL
Practice Address - Zip Code:62411-1265
Practice Address - Country:US
Practice Address - Phone:618-483-5171
Practice Address - Fax:618-483-6793
Is Sole Proprietor?:No
Enumeration Date:2023-09-26
Last Update Date:2023-09-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL041.248674163WS0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WS0200XNursing Service ProvidersRegistered NurseSchool