Provider Demographics
NPI:1609455591
Name:THILTGEN, LISA R (APRN)
Entity Type:Individual
Prefix:
First Name:LISA
Middle Name:R
Last Name:THILTGEN
Suffix:
Gender:F
Credentials:APRN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1256 WATERFORD DR STE 230
Mailing Address - Street 2:
Mailing Address - City:AURORA
Mailing Address - State:IL
Mailing Address - Zip Code:60504-4511
Mailing Address - Country:US
Mailing Address - Phone:630-978-6204
Mailing Address - Fax:630-499-2399
Practice Address - Street 1:3329 N RICHMOND ST
Practice Address - Street 2:
Practice Address - City:APPLETON
Practice Address - State:WI
Practice Address - Zip Code:54911-1063
Practice Address - Country:US
Practice Address - Phone:920-380-2715
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-04-07
Last Update Date:2022-09-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL209022574363LF0000X
WI11786-33363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI100209638Medicaid