Provider Demographics
NPI:1790037950
Name:CUNNINGHAM, LISA A (FNP)
Entity Type:Individual
Prefix:
First Name:LISA
Middle Name:A
Last Name:CUNNINGHAM
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 2580
Mailing Address - Street 2:
Mailing Address - City:SPRINGFIELD
Mailing Address - State:MO
Mailing Address - Zip Code:65801-2580
Mailing Address - Country:US
Mailing Address - Phone:417-829-4620
Mailing Address - Fax:
Practice Address - Street 1:1605 MARTIN SPRINGS DR
Practice Address - Street 2:STE 250
Practice Address - City:ROLLA
Practice Address - State:MO
Practice Address - Zip Code:65401-2931
Practice Address - Country:US
Practice Address - Phone:573-458-6363
Practice Address - Fax:573-458-6765
Is Sole Proprietor?:No
Enumeration Date:2012-10-11
Last Update Date:2019-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2012035124363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO1790037950Medicaid
MO431560263OtherTRICARE
MOP01116108OtherRR MCR
MO1790037950Medicaid