Provider Demographics
NPI:1710185079
Name:MCCANLESS, LISE MICHELLE (APRN)
Entity Type:Individual
Prefix:
First Name:LISE
Middle Name:MICHELLE
Last Name:MCCANLESS
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 1:380 TERN DR APT 3
Mailing Address - Street 2:
Mailing Address - City:NAPLES
Mailing Address - State:FL
Mailing Address - Zip Code:34112-3922
Mailing Address - Country:US
Mailing Address - Phone:757-457-5100
Mailing Address - Fax:757-819-7762
Practice Address - Street 1:8831 IMMOKALEE RD
Practice Address - Street 2:
Practice Address - City:NAPLES
Practice Address - State:FL
Practice Address - Zip Code:34120-3914
Practice Address - Country:US
Practice Address - Phone:757-457-5100
Practice Address - Fax:757-819-7762
Is Sole Proprietor?:No
Enumeration Date:2007-07-10
Last Update Date:2016-07-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VI9876363LF0000X
VA0024118550363L00000X
FLARNP9436627363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner