Provider Demographics
NPI:1568036630
Name:ETTIENNE, LISA DANITA (DNP)
Entity Type:Individual
Prefix:DR
First Name:LISA
Middle Name:DANITA
Last Name:ETTIENNE
Suffix:
Gender:F
Credentials:DNP
Other - Prefix:
Other - First Name:LISA
Other - Middle Name:DANITA
Other - Last Name:PAYNE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:4375 N 53RD ST
Mailing Address - Street 2:
Mailing Address - City:MILWAUKEE
Mailing Address - State:WI
Mailing Address - Zip Code:53216-1356
Mailing Address - Country:US
Mailing Address - Phone:414-462-8350
Mailing Address - Fax:
Practice Address - Street 1:4375 N 53RD ST
Practice Address - Street 2:
Practice Address - City:MILWAUKEE
Practice Address - State:WI
Practice Address - Zip Code:53216-1356
Practice Address - Country:US
Practice Address - Phone:414-462-8350
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-05-13
Last Update Date:2021-05-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WIF04210251363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily