Provider Demographics
NPI:1609051135
Name:PROVENZANO, LISA (NP)
Entity Type:Individual
Prefix:
First Name:LISA
Middle Name:
Last Name:PROVENZANO
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:359 ENTERPRISE CT SPC B
Mailing Address - Street 2:
Mailing Address - City:BLOOMFIELD HILLS
Mailing Address - State:MI
Mailing Address - Zip Code:48302-1055
Mailing Address - Country:US
Mailing Address - Phone:248-751-7246
Mailing Address - Fax:248-418-2311
Practice Address - Street 1:359 ENTERPRISE CT SPC B
Practice Address - Street 2:
Practice Address - City:BLOOMFIELD HILLS
Practice Address - State:MI
Practice Address - Zip Code:48302-1055
Practice Address - Country:US
Practice Address - Phone:248-751-7246
Practice Address - Fax:248-418-2311
Is Sole Proprietor?:No
Enumeration Date:2008-01-03
Last Update Date:2023-05-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4704150069363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner