Provider Demographics
NPI:1942367990
Name:WIENER, LISA A (CRNP,CNM)
Entity Type:Individual
Prefix:MS
First Name:LISA
Middle Name:A
Last Name:WIENER
Suffix:
Gender:F
Credentials:CRNP,CNM
Other - Prefix:
Other - First Name:LISA
Other - Middle Name:
Other - Last Name:GRAEF
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:4379 RIDGEWOOD CENTER DR
Mailing Address - Street 2:STE 102
Mailing Address - City:WOODBRIDGE
Mailing Address - State:VA
Mailing Address - Zip Code:22192-8322
Mailing Address - Country:US
Mailing Address - Phone:703-680-7950
Mailing Address - Fax:703-680-7953
Practice Address - Street 1:4379 RIDGEWOOD CENTER DR
Practice Address - Street 2:STE 102
Practice Address - City:WOODBRIDGE
Practice Address - State:VA
Practice Address - Zip Code:22192-8323
Practice Address - Country:US
Practice Address - Phone:703-680-7950
Practice Address - Fax:703-680-7953
Is Sole Proprietor?:No
Enumeration Date:2007-01-02
Last Update Date:2012-05-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0001096818363LF0000X
VA0024096818367A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367A00000XPhysician Assistants & Advanced Practice Nursing ProvidersAdvanced Practice Midwife
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
P91733Medicare UPIN
012011M92Medicare ID - Type Unspecified