Provider Demographics
NPI:1750013447
Name:HANBACK, LISA ROMEO (FNP-BC)
Entity Type:Individual
Prefix:
First Name:LISA
Middle Name:ROMEO
Last Name:HANBACK
Suffix:
Gender:F
Credentials:FNP-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8081 INNOVATION PARK DR STE 301
Mailing Address - Street 2:
Mailing Address - City:FAIRFAX
Mailing Address - State:VA
Mailing Address - Zip Code:22031-4867
Mailing Address - Country:US
Mailing Address - Phone:571-472-6431
Mailing Address - Fax:
Practice Address - Street 1:8081 INNOVATION PARK DR STE 301
Practice Address - Street 2:
Practice Address - City:FAIRFAX
Practice Address - State:VA
Practice Address - Zip Code:22031-4867
Practice Address - Country:US
Practice Address - Phone:571-472-6431
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-06-30
Last Update Date:2022-08-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0024184584363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily