Provider Demographics
NPI:1871841338
Name:TATE, LISA ANN (ATC)
Entity Type:Individual
Prefix:MRS
First Name:LISA
Middle Name:ANN
Last Name:TATE
Suffix:
Gender:F
Credentials:ATC
Other - Prefix:MS
Other - First Name:LISA
Other - Middle Name:ANN
Other - Last Name:JACKSON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:ATC
Mailing Address - Street 1:2312 S DIXON RD
Mailing Address - Street 2:SUITE 250
Mailing Address - City:KOKOMO
Mailing Address - State:IN
Mailing Address - Zip Code:46902-6401
Mailing Address - Country:US
Mailing Address - Phone:765-455-2122
Mailing Address - Fax:765-455-3122
Practice Address - Street 1:2312 S DIXON RD
Practice Address - Street 2:SUITE 250
Practice Address - City:KOKOMO
Practice Address - State:IN
Practice Address - Zip Code:46902-6401
Practice Address - Country:US
Practice Address - Phone:765-455-2122
Practice Address - Fax:765-455-3122
Is Sole Proprietor?:No
Enumeration Date:2012-08-15
Last Update Date:2012-08-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN36000648A2255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer