Provider Demographics
NPI:1568972156
Name:MIRACLE, LISA M (CNP)
Entity Type:Individual
Prefix:MRS
First Name:LISA
Middle Name:M
Last Name:MIRACLE
Suffix:
Gender:F
Credentials:CNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4912 SHANKS PHALANX RD
Mailing Address - Street 2:
Mailing Address - City:SOUTHINGTON
Mailing Address - State:OH
Mailing Address - Zip Code:44470-9534
Mailing Address - Country:US
Mailing Address - Phone:330-360-5415
Mailing Address - Fax:
Practice Address - Street 1:444 W EXCHANGE ST
Practice Address - Street 2:
Practice Address - City:AKRON
Practice Address - State:OH
Practice Address - Zip Code:44302-1711
Practice Address - Country:US
Practice Address - Phone:330-535-2671
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-10-09
Last Update Date:2017-10-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHAPRN.CNP.021517363LW0102X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LW0102XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerWomen's Health