Provider Demographics
NPI:1629546411
Name:SUWANAWONGSE, LISA JO (FNP-BC)
Entity Type:Individual
Prefix:
First Name:LISA
Middle Name:JO
Last Name:SUWANAWONGSE
Suffix:
Gender:F
Credentials:FNP-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 428
Mailing Address - Street 2:
Mailing Address - City:HARRISBURG
Mailing Address - State:IL
Mailing Address - Zip Code:62946-0428
Mailing Address - Country:US
Mailing Address - Phone:618-253-7671
Mailing Address - Fax:618-253-0474
Practice Address - Street 1:100 DR WARREN TUTTLE DR
Practice Address - Street 2:
Practice Address - City:HARRISBURG
Practice Address - State:IL
Practice Address - Zip Code:62946-2718
Practice Address - Country:US
Practice Address - Phone:618-253-7671
Practice Address - Fax:618-253-0474
Is Sole Proprietor?:No
Enumeration Date:2018-11-09
Last Update Date:2018-11-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL209016422363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily