Provider Demographics
NPI:1518039205
Name:UNCLES, LISA BETINA (CNM)
Entity Type:Individual
Prefix:MS
First Name:LISA
Middle Name:BETINA
Last Name:UNCLES
Suffix:
Gender:F
Credentials:CNM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:259 WAXTER WAY
Mailing Address - Street 2:
Mailing Address - City:BALTIMORE
Mailing Address - State:MD
Mailing Address - Zip Code:21217-4142
Mailing Address - Country:US
Mailing Address - Phone:202-398-5520
Mailing Address - Fax:202-396-6953
Practice Address - Street 1:801 17TH ST NE
Practice Address - Street 2:
Practice Address - City:WASHINGTON
Practice Address - State:DC
Practice Address - Zip Code:20002-7200
Practice Address - Country:US
Practice Address - Phone:202-398-5520
Practice Address - Fax:202-396-6953
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-15
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DCRN1008706367A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367A00000XPhysician Assistants & Advanced Practice Nursing ProvidersAdvanced Practice Midwife