Provider Demographics
NPI:1700196888
Name:MCCONNELL, LISA MARIE (FNP-BC)
Entity Type:Individual
Prefix:MS
First Name:LISA
Middle Name:MARIE
Last Name:MCCONNELL
Suffix:
Gender:F
Credentials:FNP-BC
Other - Prefix:
Other - First Name:LISA
Other - Middle Name:MARIE
Other - Last Name:NELSON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:FNP-BC
Mailing Address - Street 1:2350 W EL CAMINO REAL FL 2
Mailing Address - Street 2:
Mailing Address - City:MOUNTAIN VIEW
Mailing Address - State:CA
Mailing Address - Zip Code:94040-6203
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2751 RESEARCH PARK DR
Practice Address - Street 2:
Practice Address - City:SOQUEL
Practice Address - State:CA
Practice Address - Zip Code:95073-2037
Practice Address - Country:US
Practice Address - Phone:800-972-5547
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-10-07
Last Update Date:2019-03-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4704161913363LF0000X
CA14114363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAP92259Medicare UPIN
MION53270Medicare PIN