Provider Demographics
NPI:1497792485
Name:LANGE, LISA MONICA (CNP)
Entity Type:Individual
Prefix:
First Name:LISA
Middle Name:MONICA
Last Name:LANGE
Suffix:
Gender:F
Credentials:CNP
Other - Prefix:
Other - First Name:LISA
Other - Middle Name:MONICA
Other - Last Name:MALBURG
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:CNP
Mailing Address - Street 1:1560 E MAPLE RD STE 400
Mailing Address - Street 2:
Mailing Address - City:TROY
Mailing Address - State:MI
Mailing Address - Zip Code:48083-1135
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:4100 JOHN R
Practice Address - Street 2:KARMANOS CANCER CTR MIDLEVELS
Practice Address - City:DETROIT
Practice Address - State:MI
Practice Address - Zip Code:48201-2013
Practice Address - Country:US
Practice Address - Phone:800-527-6266
Practice Address - Fax:313-576-8381
Is Sole Proprietor?:No
Enumeration Date:2006-05-31
Last Update Date:2018-12-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4704173236363LA2200X, 363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI0P32180004Medicare PIN