Provider Demographics
NPI:1598542383
Name:SOTELO, LISA SUE
Entity Type:Individual
Prefix:
First Name:LISA
Middle Name:SUE
Last Name:SOTELO
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 1:2230 288TH DR
Mailing Address - Street 2:
Mailing Address - City:WILLIAMSBURG
Mailing Address - State:IA
Mailing Address - Zip Code:52361-8736
Mailing Address - Country:US
Mailing Address - Phone:319-331-9742
Mailing Address - Fax:
Practice Address - Street 1:605 E WINFIELD AVE
Practice Address - Street 2:
Practice Address - City:MT PLEASANT
Practice Address - State:IA
Practice Address - Zip Code:52641-2928
Practice Address - Country:US
Practice Address - Phone:319-385-8051
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-09-13
Last Update Date:2023-09-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IAG176317363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health