Provider Demographics
NPI:1588644454
Name:HENNEN, LISA R (CNP)
Entity Type:Individual
Prefix:
First Name:LISA
Middle Name:R
Last Name:HENNEN
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 1:720 4TH AVE S
Mailing Address - Street 2:
Mailing Address - City:SAINT CLOUD
Mailing Address - State:MN
Mailing Address - Zip Code:56301-4442
Mailing Address - Country:US
Mailing Address - Phone:320-308-3191
Mailing Address - Fax:320-308-3192
Practice Address - Street 1:720 4TH AVE S
Practice Address - Street 2:
Practice Address - City:SAINT CLOUD
Practice Address - State:MN
Practice Address - Zip Code:56301-4498
Practice Address - Country:US
Practice Address - Phone:320-308-3191
Practice Address - Fax:320-308-3192
Is Sole Proprietor?:No
Enumeration Date:2006-01-18
Last Update Date:2020-11-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN2121363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN862953600Medicaid
MNP00221874OtherRR MEDICARE
MN862953600Medicaid
Q00013Medicare UPIN
MN6697670002Medicare NSC