Provider Demographics
NPI:1851431076
Name:LIRA, KRISTINE R (NP)
Entity Type:Individual
Prefix:MRS
First Name:KRISTINE
Middle Name:R
Last Name:LIRA
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10717 67TH ST
Mailing Address - Street 2:
Mailing Address - City:KENOSHA
Mailing Address - State:WI
Mailing Address - Zip Code:53142-7545
Mailing Address - Country:US
Mailing Address - Phone:262-764-0493
Mailing Address - Fax:
Practice Address - Street 1:1870 W WINCHESTER RD
Practice Address - Street 2:SUITE 143
Practice Address - City:LIBERTYVILLE
Practice Address - State:IL
Practice Address - Zip Code:60048-5358
Practice Address - Country:US
Practice Address - Phone:847-549-7777
Practice Address - Fax:847-549-7779
Is Sole Proprietor?:No
Enumeration Date:2007-02-07
Last Update Date:2022-10-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL209003659363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILP67858Medicare UPIN
IL202760Medicare ID - Type Unspecified