Provider Demographics
NPI:1689072738
Name:RINKE, LISA DIANE (FNP-BC)
Entity Type:Individual
Prefix:
First Name:LISA
Middle Name:DIANE
Last Name:RINKE
Suffix:
Gender:F
Credentials:FNP-BC
Other - Prefix:
Other - First Name:LISA
Other - Middle Name:DIANE
Other - Last Name:SUROVICK
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:17120 KERCHEVAL AVE
Mailing Address - Street 2:
Mailing Address - City:GROSSE POINTE
Mailing Address - State:MI
Mailing Address - Zip Code:48230-1661
Mailing Address - Country:US
Mailing Address - Phone:313-886-3300
Mailing Address - Fax:
Practice Address - Street 1:17120 KERCHEVAL AVE
Practice Address - Street 2:
Practice Address - City:GROSSE POINTE
Practice Address - State:MI
Practice Address - Zip Code:48230-1661
Practice Address - Country:US
Practice Address - Phone:318-886-3300
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-12-05
Last Update Date:2020-09-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4714147850363LF0000X
MI4704147850363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY3008817OtherLICENSE
MI4704147850OtherLICENSE