Provider Demographics
NPI:1750653697
Name:PORTHOUSE, LISA (CNM)
Entity Type:Individual
Prefix:
First Name:LISA
Middle Name:
Last Name:PORTHOUSE
Suffix:
Gender:F
Credentials:CNM
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Other - First Name:
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Mailing Address - Street 1:621 S NEW BALLAS RD
Mailing Address - Street 2:SUITE 2009 B
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63141-8232
Mailing Address - Country:US
Mailing Address - Phone:314-251-6000
Mailing Address - Fax:314-251-4376
Practice Address - Street 1:621 S NEW BALLAS RD
Practice Address - Street 2:SUITE 2009 B
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63141-8232
Practice Address - Country:US
Practice Address - Phone:314-251-6000
Practice Address - Fax:314-251-4376
Is Sole Proprietor?:Yes
Enumeration Date:2012-02-08
Last Update Date:2013-06-24
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Provider Licenses
StateLicense IDTaxonomies
MO113826367A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367A00000XPhysician Assistants & Advanced Practice Nursing ProvidersAdvanced Practice Midwife