Provider Demographics
NPI:1639235682
Name:LIS, GAIL ANN (APRN BC)
Entity Type:Individual
Prefix:MRS
First Name:GAIL
Middle Name:ANN
Last Name:LIS
Suffix:
Gender:F
Credentials:APRN BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:48748 DELMONT DR
Mailing Address - Street 2:
Mailing Address - City:NOVI
Mailing Address - State:MI
Mailing Address - Zip Code:48374-2767
Mailing Address - Country:US
Mailing Address - Phone:248-380-9978
Mailing Address - Fax:
Practice Address - Street 1:16010 19 MILE RD
Practice Address - Street 2:SUITE 101
Practice Address - City:CLINTON TWP
Practice Address - State:MI
Practice Address - Zip Code:48038-1141
Practice Address - Country:US
Practice Address - Phone:586-286-8674
Practice Address - Fax:586-286-5564
Is Sole Proprietor?:No
Enumeration Date:2006-12-27
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4704132475363LA2100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2100XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAcute Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI50-0-86-6974-0OtherBCBSM
MI0N64240Medicare ID - Type Unspecified