Provider Demographics
NPI:1760717581
Name:LISBURG, ANGELA ALICE (NP-C)
Entity Type:Individual
Prefix:
First Name:ANGELA
Middle Name:ALICE
Last Name:LISBURG
Suffix:
Gender:F
Credentials:NP-C
Other - Prefix:
Other - First Name:ANGELA
Other - Middle Name:ALICE
Other - Last Name:VANDENDRIESSCHE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:801 E SIOUX AVE
Mailing Address - Street 2:
Mailing Address - City:PIERRE
Mailing Address - State:SD
Mailing Address - Zip Code:57501-3323
Mailing Address - Country:US
Mailing Address - Phone:605-224-3229
Mailing Address - Fax:605-224-3230
Practice Address - Street 1:801 E SIOUX AVE
Practice Address - Street 2:
Practice Address - City:PIERRE
Practice Address - State:SD
Practice Address - Zip Code:57501-3323
Practice Address - Country:US
Practice Address - Phone:605-224-3229
Practice Address - Fax:605-224-3230
Is Sole Proprietor?:No
Enumeration Date:2009-10-13
Last Update Date:2010-11-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SDCP000605363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily