Provider Demographics
NPI:1558688747
Name:UKHANOVA, LIZA (FNP-BC)
Entity Type:Individual
Prefix:
First Name:LIZA
Middle Name:
Last Name:UKHANOVA
Suffix:
Gender:F
Credentials:FNP-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2135 PINE RIDGE CT
Mailing Address - Street 2:UNIT A
Mailing Address - City:GRAFTON
Mailing Address - State:WI
Mailing Address - Zip Code:53024-3104
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:302 N JACKSON ST
Practice Address - Street 2:
Practice Address - City:MILWAUKEE
Practice Address - State:WI
Practice Address - Zip Code:53202-5904
Practice Address - Country:US
Practice Address - Phone:414-271-8045
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-04-27
Last Update Date:2015-02-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI2009008877363L00000X
WI4050-33363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily