Provider Demographics
NPI:1629637921
Name:MACLELLAN, LISA SONIA (FNP-C)
Entity Type:Individual
Prefix:
First Name:LISA
Middle Name:SONIA
Last Name:MACLELLAN
Suffix:
Gender:F
Credentials:FNP-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5200 W BEEMAN RD
Mailing Address - Street 2:
Mailing Address - City:EMPIRE
Mailing Address - State:MI
Mailing Address - Zip Code:49630-9739
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:3250 WOODS WAY STE 5
Practice Address - Street 2:
Practice Address - City:PETOSKEY
Practice Address - State:MI
Practice Address - Zip Code:49770-7628
Practice Address - Country:US
Practice Address - Phone:231-881-9700
Practice Address - Fax:231-881-9698
Is Sole Proprietor?:Yes
Enumeration Date:2019-06-10
Last Update Date:2019-08-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4704242836363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner