Provider Demographics
NPI:1790325660
Name:SOFOCLEOUS, LISA CORINNE (CNP)
Entity Type:Individual
Prefix:
First Name:LISA
Middle Name:CORINNE
Last Name:SOFOCLEOUS
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 1:250 BRODBELT LN APT 204
Mailing Address - Street 2:
Mailing Address - City:COLUMBUS
Mailing Address - State:OH
Mailing Address - Zip Code:43215-2458
Mailing Address - Country:US
Mailing Address - Phone:330-540-7636
Mailing Address - Fax:
Practice Address - Street 1:250 BRODBELT LN APT 204
Practice Address - Street 2:
Practice Address - City:COLUMBUS
Practice Address - State:OH
Practice Address - Zip Code:43215-2458
Practice Address - Country:US
Practice Address - Phone:330-540-7636
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-01-08
Last Update Date:2020-01-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHAPRN.CNP.025876363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
OHAPRN.CNP.025876OtherOHIO BOARD OF NURSING
OHF08190884OtherOHIO BOARD OF NURSING