Provider Demographics
NPI:1629260716
Name:ANTLE, LISA LAUREN (APRN/BC/APNP)
Entity Type:Individual
Prefix:MS
First Name:LISA
Middle Name:LAUREN
Last Name:ANTLE
Suffix:
Gender:F
Credentials:APRN/BC/APNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Mailing Address - Street 1:3915 N RIDGEFIELD CIR
Mailing Address - Street 2:
Mailing Address - City:SHOREWOOD
Mailing Address - State:WI
Mailing Address - Zip Code:53211-2451
Mailing Address - Country:US
Mailing Address - Phone:414-467-4162
Mailing Address - Fax:414-906-1758
Practice Address - Street 1:3915 N RIDGEFIELD CIR
Practice Address - Street 2:
Practice Address - City:SHOREWOOD
Practice Address - State:WI
Practice Address - Zip Code:53211-2451
Practice Address - Country:US
Practice Address - Phone:414-467-4162
Practice Address - Fax:414-906-1758
Is Sole Proprietor?:Yes
Enumeration Date:2007-08-13
Last Update Date:2007-08-13
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
WI2531-033364SG0600X
WI364SG0600X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes364SG0600XPhysician Assistants & Advanced Practice Nursing ProvidersClinical Nurse SpecialistGerontology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MOP32219Medicare UPIN