Provider Demographics
NPI:1922592369
Name:WHITACRE, LIZA JENNIFER (CNP)
Entity Type:Individual
Prefix:MRS
First Name:LIZA
Middle Name:JENNIFER
Last Name:WHITACRE
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 1:6009 MITCHAW RD
Mailing Address - Street 2:
Mailing Address - City:SYLVANIA
Mailing Address - State:OH
Mailing Address - Zip Code:43560-9410
Mailing Address - Country:US
Mailing Address - Phone:419-494-6638
Mailing Address - Fax:
Practice Address - Street 1:7443 JACKMAN RD
Practice Address - Street 2:
Practice Address - City:TEMPERANCE
Practice Address - State:MI
Practice Address - Zip Code:48182
Practice Address - Country:US
Practice Address - Phone:734-850-0112
Practice Address - Fax:734-850-0100
Is Sole Proprietor?:No
Enumeration Date:2018-06-19
Last Update Date:2018-08-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4704345718363LF0000X
OHAPRN.CNP.02265363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
OHPENDINGMedicaid
MIPENDINGMedicaid