Provider Demographics
NPI:1760688287
Name:PARKS, LISA SHEPPARD (CNP)
Entity Type:Individual
Prefix:MS
First Name:LISA
Middle Name:SHEPPARD
Last Name:PARKS
Suffix:
Gender:F
Credentials:CNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:700 ACKERMAN RD STE 570
Mailing Address - Street 2:
Mailing Address - City:COLUMBUS
Mailing Address - State:OH
Mailing Address - Zip Code:43202-1579
Mailing Address - Country:US
Mailing Address - Phone:614-685-4990
Mailing Address - Fax:614-293-3465
Practice Address - Street 1:460 W 10TH AVE STE D1900
Practice Address - Street 2:
Practice Address - City:COLUMBUS
Practice Address - State:OH
Practice Address - Zip Code:43210-1240
Practice Address - Country:US
Practice Address - Phone:614-293-7171
Practice Address - Fax:614-293-3465
Is Sole Proprietor?:No
Enumeration Date:2007-06-22
Last Update Date:2018-01-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHRN.167394163W00000X
OHAPRN.CNP.00194363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health
No163W00000XNursing Service ProvidersRegistered Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0253911Medicaid