Provider Demographics
NPI:1669471439
Name:WONNELL-CHIZMAR, LISA MARIE (NP)
Entity Type:Individual
Prefix:
First Name:LISA
Middle Name:MARIE
Last Name:WONNELL-CHIZMAR
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 1:580 SUGAR MAPLE CT
Mailing Address - Street 2:
Mailing Address - City:MAUMEE
Mailing Address - State:OH
Mailing Address - Zip Code:43537-2306
Mailing Address - Country:US
Mailing Address - Phone:419-897-7851
Mailing Address - Fax:
Practice Address - Street 1:7053 W CENTRAL AVE
Practice Address - Street 2:
Practice Address - City:TOLEDO
Practice Address - State:OH
Practice Address - Zip Code:43617-1114
Practice Address - Country:US
Practice Address - Phone:419-843-1370
Practice Address - Fax:419-843-1362
Is Sole Proprietor?:No
Enumeration Date:2005-07-14
Last Update Date:2007-11-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH07055363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2352332Medicaid
OH9282351Medicare PIN
OH9282357Medicare PIN
OH2352332Medicaid
OH71419Medicare UPIN
OH9282356Medicare PIN
OH9282354Medicare PIN
OH76731Medicare ID - Type Unspecified
OH9282353Medicare PIN