Provider Demographics
NPI:1104155605
Name:KING, LISA JENNIFER (CRNP)
Entity type:Individual
Prefix:MRS
First Name:LISA
Middle Name:JENNIFER
Last Name:KING
Suffix:
Gender:F
Credentials:CRNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:1025 S TRIMBLE RD
Mailing Address - Street 2:
Mailing Address - City:MANSFIELD
Mailing Address - State:OH
Mailing Address - Zip Code:44906-3427
Mailing Address - Country:US
Mailing Address - Phone:419-589-9700
Mailing Address - Fax:419-589-2103
Practice Address - Street 1:70 MADISON RD
Practice Address - Street 2:
Practice Address - City:MANSFIELD
Practice Address - State:OH
Practice Address - Zip Code:44905-2831
Practice Address - Country:US
Practice Address - Phone:419-589-9700
Practice Address - Fax:419-589-2731
Is Sole Proprietor?:Yes
Enumeration Date:2009-12-11
Last Update Date:2016-03-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHCOA.11067-NP363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner