Provider Demographics
NPI:1891239794
Name:WHITE, LISA (LAC)
Entity Type:Individual
Prefix:
First Name:LISA
Middle Name:
Last Name:WHITE
Suffix:
Gender:F
Credentials:LAC
Other - Prefix:
Other - First Name:LISA
Other - Middle Name:
Other - Last Name:GRIEVES
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:LAC
Mailing Address - Street 1:2254 S TISSAW RD
Mailing Address - Street 2:
Mailing Address - City:CORNVILLE
Mailing Address - State:AZ
Mailing Address - Zip Code:86325-4924
Mailing Address - Country:US
Mailing Address - Phone:303-478-0783
Mailing Address - Fax:
Practice Address - Street 1:60 TORTILLA DR.
Practice Address - Street 2:NAMTI SPA
Practice Address - City:SEDONA
Practice Address - State:AZ
Practice Address - Zip Code:86336
Practice Address - Country:US
Practice Address - Phone:928-282-7737
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-12-12
Last Update Date:2016-12-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ1017171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist