Provider Demographics
NPI:1508973074
Name:VAN TINE, LISA LEILANI (CPNP,CNS)
Entity Type:Individual
Prefix:
First Name:LISA
Middle Name:LEILANI
Last Name:VAN TINE
Suffix:
Gender:F
Credentials:CPNP,CNS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3701 S BROADWAY
Mailing Address - Street 2:
Mailing Address - City:ENGLEWOOD
Mailing Address - State:CO
Mailing Address - Zip Code:80113-3611
Mailing Address - Country:US
Mailing Address - Phone:303-761-1977
Mailing Address - Fax:303-761-2787
Practice Address - Street 1:3292 PEORIA ST
Practice Address - Street 2:
Practice Address - City:AURORA
Practice Address - State:CO
Practice Address - Zip Code:80010-1517
Practice Address - Country:US
Practice Address - Phone:303-343-6130
Practice Address - Fax:303-344-0664
Is Sole Proprietor?:No
Enumeration Date:2006-08-23
Last Update Date:2019-01-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CORN.0127666163W00000X
CORXN.0006301-NP363L00000X
COAPN.0004136-NP363LP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPediatrics
No163W00000XNursing Service ProvidersRegistered Nurse
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner