Provider Demographics
NPI:1013148980
Name:HUBBARD, LISA (CFNP)
Entity Type:Individual
Prefix:
First Name:LISA
Middle Name:
Last Name:HUBBARD
Suffix:
Gender:F
Credentials:CFNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10625 W NORTH AVE
Mailing Address - Street 2:SUITE 102
Mailing Address - City:MILWAUKEE
Mailing Address - State:WI
Mailing Address - Zip Code:53226-2315
Mailing Address - Country:US
Mailing Address - Phone:414-877-5350
Mailing Address - Fax:414-877-5360
Practice Address - Street 1:5000 W CHAMBERS ST
Practice Address - Street 2:
Practice Address - City:MILWAUKEE
Practice Address - State:WI
Practice Address - Zip Code:53210-1650
Practice Address - Country:US
Practice Address - Phone:414-447-2000
Practice Address - Fax:414-874-4393
Is Sole Proprietor?:No
Enumeration Date:2009-07-27
Last Update Date:2017-05-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI122075-30207P00000X, 363L00000X
WI3835-33363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI1013148980OtherBLUE CROSS BLUE SHIELD
WI014730093Medicare PIN
WI029050152Medicare PIN