Provider Demographics
NPI:1922232131
Name:WHEELER, LISA A (PNP)
Entity Type:Individual
Prefix:
First Name:LISA
Middle Name:A
Last Name:WHEELER
Suffix:
Gender:F
Credentials:PNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:315 N WASHINGTON AVE
Mailing Address - Street 2:STE 190
Mailing Address - City:COOKEVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:38501-5984
Mailing Address - Country:US
Mailing Address - Phone:931-528-3300
Mailing Address - Fax:313-722-1029
Practice Address - Street 1:315 N WASHINGTON AVE
Practice Address - Street 2:STE 190
Practice Address - City:COOKEVILLE
Practice Address - State:TN
Practice Address - Zip Code:38501-5984
Practice Address - Country:US
Practice Address - Phone:931-528-3300
Practice Address - Fax:313-722-1029
Is Sole Proprietor?:No
Enumeration Date:2009-05-04
Last Update Date:2020-08-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNRN79264363LP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN1517710Medicaid
TN1512648Medicaid
TN3001286Medicaid
TN3001286Medicaid
TN1517710Medicaid