Provider Demographics
NPI:1710070495
Name:MCINTOSH, LISA DENISE (APRN)
Entity Type:Individual
Prefix:
First Name:LISA
Middle Name:DENISE
Last Name:MCINTOSH
Suffix:
Gender:F
Credentials:APRN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1674 STATE ROUTE 176
Mailing Address - Street 2:
Mailing Address - City:GREENVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:42345-4122
Mailing Address - Country:US
Mailing Address - Phone:270-476-3374
Mailing Address - Fax:270-476-4324
Practice Address - Street 1:1674 STATE ROUTE 176
Practice Address - Street 2:
Practice Address - City:GREENVILLE
Practice Address - State:KY
Practice Address - Zip Code:42345-4122
Practice Address - Country:US
Practice Address - Phone:270-476-3374
Practice Address - Fax:270-476-4324
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-02
Last Update Date:2020-02-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY3004369363LF0000X
KY4369P363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY0000000346150OtherANTHEM
KY78013646Medicaid
KY78013646Medicaid
KY1593403Medicare PIN