Provider Demographics
NPI:1619519469
Name:STEVENS, LISA PETERSON (NP)
Entity Type:Individual
Prefix:
First Name:LISA
Middle Name:PETERSON
Last Name:STEVENS
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:LISA
Other - Middle Name:PETERSON
Other - Last Name:HANEY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:RN
Mailing Address - Street 1:4460 S HIGHLAND DR STE 210
Mailing Address - Street 2:
Mailing Address - City:SALT LAKE CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84124-3550
Mailing Address - Country:US
Mailing Address - Phone:888-949-4864
Mailing Address - Fax:
Practice Address - Street 1:4460 S HIGHLAND DR STE 210
Practice Address - Street 2:
Practice Address - City:SALT LAKE CITY
Practice Address - State:UT
Practice Address - Zip Code:84124-3550
Practice Address - Country:US
Practice Address - Phone:888-949-4864
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-10-14
Last Update Date:2019-12-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT8739478-3102163W00000X
UT8739478-4405363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No163W00000XNursing Service ProvidersRegistered Nurse