Provider Demographics
NPI:1073662078
Name:LISTERHENDRIX, JOSEPHINE L (NP)
Entity type:Individual
Prefix:
First Name:JOSEPHINE
Middle Name:L
Last Name:LISTERHENDRIX
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:JOSEPHINE
Other - Middle Name:L
Other - Last Name:LISTER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:NP
Mailing Address - Street 1:2218 BIRCHWOOD CT
Mailing Address - Street 2:
Mailing Address - City:TRAVERSE CITY
Mailing Address - State:MI
Mailing Address - Zip Code:49686-2024
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:123 RETIRED
Practice Address - Street 2:
Practice Address - City:TRAVERSE CITY
Practice Address - State:MI
Practice Address - Zip Code:49686
Practice Address - Country:US
Practice Address - Phone:231-357-4814
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-01-09
Last Update Date:2022-04-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4704128272363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
MIS85804Medicare UPIN