Provider Demographics
NPI:1477529261
Name:FORD, LISA RENEE' (FNP)
Entity Type:Individual
Prefix:
First Name:LISA
Middle Name:RENEE'
Last Name:FORD
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:
Other - First Name:LISA
Other - Middle Name:RENEE'
Other - Last Name:FORD
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:FNP
Mailing Address - Street 1:55 LOBSTERTAIL RD
Mailing Address - Street 2:
Mailing Address - City:BIG PINE KEY
Mailing Address - State:FL
Mailing Address - Zip Code:33043-3312
Mailing Address - Country:US
Mailing Address - Phone:931-206-9488
Mailing Address - Fax:
Practice Address - Street 1:5005 N PIEDRAS STREET
Practice Address - Street 2:
Practice Address - City:EL PASO
Practice Address - State:TX
Practice Address - Zip Code:79920
Practice Address - Country:US
Practice Address - Phone:915-742-1390
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-02-23
Last Update Date:2021-06-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN17686363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily