Provider Demographics
NPI:1255605754
Name:CONNER, LISA MARIE (NP)
Entity type:Individual
Prefix:
First Name:LISA
Middle Name:MARIE
Last Name:CONNER
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:18077 RIVER RD STE 104A
Mailing Address - Street 2:
Mailing Address - City:NOBLESVILLE
Mailing Address - State:IN
Mailing Address - Zip Code:46062-8311
Mailing Address - Country:US
Mailing Address - Phone:317-674-0208
Mailing Address - Fax:
Practice Address - Street 1:18077 RIVER RD STE 104A
Practice Address - Street 2:
Practice Address - City:NOBLESVILLE
Practice Address - State:IN
Practice Address - Zip Code:46062-8311
Practice Address - Country:US
Practice Address - Phone:317-674-0208
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-03-01
Last Update Date:2021-03-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN71003895A363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN201053310Medicaid
IN201053310Medicaid
IN177280025Medicare UPIN