Provider Demographics
NPI:1558922492
Name:BULLIS, LISA MARIE (MSN, APNP)
Entity Type:Individual
Prefix:
First Name:LISA
Middle Name:MARIE
Last Name:BULLIS
Suffix:
Gender:F
Credentials:MSN, APNP
Other - Prefix:
Other - First Name:LISA
Other - Middle Name:MARIE
Other - Last Name:BETLEJ
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:9200 W WISCONSIN AVE
Mailing Address - Street 2:
Mailing Address - City:MILWAUKEE
Mailing Address - State:WI
Mailing Address - Zip Code:53226-3522
Mailing Address - Country:US
Mailing Address - Phone:414-955-0728
Mailing Address - Fax:414-805-4606
Practice Address - Street 1:9200 W WISCONSIN AVE
Practice Address - Street 2:
Practice Address - City:MILWAUKEE
Practice Address - State:WI
Practice Address - Zip Code:53226-3522
Practice Address - Country:US
Practice Address - Phone:414-955-0728
Practice Address - Fax:414-805-4606
Is Sole Proprietor?:No
Enumeration Date:2019-06-21
Last Update Date:2021-07-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI195913-30163W00000X
WI9484-33363LA2100X
WI9484363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No163W00000XNursing Service ProvidersRegistered Nurse
No363LA2100XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAcute Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI100092474Medicaid
WI195913-30OtherWISCONSIN STATE BOARD OF NURSING
WI9484-33OtherTHE STATE OF WISCONSIN DEPARTMENT OF SAFETY AND PROFESSIONAL SERVICES