Provider Demographics
NPI:1659608479
Name:MCCONNELL, LISA D (NP)
Entity Type:Individual
Prefix:
First Name:LISA
Middle Name:D
Last Name:MCCONNELL
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 1:2930 11TH AVE
Mailing Address - Street 2:
Mailing Address - City:EVANS
Mailing Address - State:CO
Mailing Address - Zip Code:80620-1011
Mailing Address - Country:US
Mailing Address - Phone:970-353-9403
Mailing Address - Fax:970-353-9906
Practice Address - Street 1:1300 N 17TH AVE
Practice Address - Street 2:
Practice Address - City:GREELEY
Practice Address - State:CO
Practice Address - Zip Code:80631-9584
Practice Address - Country:US
Practice Address - Phone:970-350-5313
Practice Address - Fax:970-346-1166
Is Sole Proprietor?:No
Enumeration Date:2009-11-16
Last Update Date:2013-09-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO10052363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO43180817Medicaid
CO306642Medicare Oscar/Certification
CO306642Medicare PIN