Provider Demographics
NPI:1629399696
Name:OMO-GRIFFITH, LISA (NP)
Entity Type:Individual
Prefix:
First Name:LISA
Middle Name:
Last Name:OMO-GRIFFITH
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 1:6809 COVINGTON CREEK TRL
Mailing Address - Street 2:
Mailing Address - City:FORT WAYNE
Mailing Address - State:IN
Mailing Address - Zip Code:46804-2871
Mailing Address - Country:US
Mailing Address - Phone:260-437-4173
Mailing Address - Fax:260-918-6855
Practice Address - Street 1:5646 COVENTRY LN
Practice Address - Street 2:
Practice Address - City:FORT WAYNE
Practice Address - State:IN
Practice Address - Zip Code:46804-7140
Practice Address - Country:US
Practice Address - Phone:260-203-5441
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-06-14
Last Update Date:2023-09-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN28156677163W00000X
OHCOA13460363LF0000X
IN71003136363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No163W00000XNursing Service ProvidersRegistered Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN000000682872OtherANTHEM
OH0069880Medicaid
IN200999600Medicaid
INP01044179OtherR.R. MEDICARE
INM400029473Medicare PIN
ININ1945003Medicare PIN