Provider Demographics
NPI:1497178644
Name:STAPLE, LISA (RN)
Entity Type:Individual
Prefix:
First Name:LISA
Middle Name:
Last Name:STAPLE
Suffix:
Gender:F
Credentials:RN
Other - Prefix:
Other - First Name:LISA
Other - Middle Name:
Other - Last Name:HOOGERWERF
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:RN
Mailing Address - Street 1:74 E 34TH ST
Mailing Address - Street 2:
Mailing Address - City:HOLLAND
Mailing Address - State:MI
Mailing Address - Zip Code:49423-7004
Mailing Address - Country:US
Mailing Address - Phone:616-405-2854
Mailing Address - Fax:
Practice Address - Street 1:3333 36TH ST SE
Practice Address - Street 2:
Practice Address - City:GRAND RAPIDS
Practice Address - State:MI
Practice Address - Zip Code:49512-2809
Practice Address - Country:US
Practice Address - Phone:616-954-3540
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-01-23
Last Update Date:2014-01-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4704254719163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse