Provider Demographics
NPI:1578339529
Name:HERRERA, LISET
Entity Type:Individual
Prefix:
First Name:LISET
Middle Name:
Last Name:HERRERA
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:309 WEST BLVD
Mailing Address - Street 2:
Mailing Address - City:RACINE
Mailing Address - State:WI
Mailing Address - Zip Code:53405-2144
Mailing Address - Country:US
Mailing Address - Phone:262-613-8970
Mailing Address - Fax:
Practice Address - Street 1:209 W ORCHARD ST
Practice Address - Street 2:
Practice Address - City:MILWAUKEE
Practice Address - State:WI
Practice Address - Zip Code:53204-2957
Practice Address - Country:US
Practice Address - Phone:414-647-7466
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-11-30
Last Update Date:2024-04-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI14641363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner