Provider Demographics
NPI:1922645191
Name:NEISWONGER, PAULINE LERMA (FNP)
Entity Type:Individual
Prefix:
First Name:PAULINE
Middle Name:LERMA
Last Name:NEISWONGER
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2842 E INCA LN
Mailing Address - Street 2:
Mailing Address - City:SAN TAN VALLEY
Mailing Address - State:AZ
Mailing Address - Zip Code:85140-1324
Mailing Address - Country:US
Mailing Address - Phone:480-323-3000
Mailing Address - Fax:
Practice Address - Street 1:2842 E INCA LN
Practice Address - Street 2:
Practice Address - City:SAN TAN VALLEY
Practice Address - State:AZ
Practice Address - Zip Code:85140-1324
Practice Address - Country:US
Practice Address - Phone:480-323-3000
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-12-05
Last Update Date:2021-05-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ234646363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamilyGroup - Single Specialty