Provider Demographics
NPI:1265206692
Name:FERNANDES, LISA MARIE (LPN)
Entity type:Individual
Prefix:MRS
First Name:LISA
Middle Name:MARIE
Last Name:FERNANDES
Suffix:
Gender:F
Credentials:LPN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1429 S. MAIN ST. DHS/DRS/HSD
Mailing Address - Street 2:SUITE C
Mailing Address - City:JACKSONVILLE
Mailing Address - State:IL
Mailing Address - Zip Code:62650
Mailing Address - Country:US
Mailing Address - Phone:217-245-9585
Mailing Address - Fax:
Practice Address - Street 1:1429 S. MAIN ST. DHS/DRS/HSD
Practice Address - Street 2:SUITE C
Practice Address - City:JACKSONVILLE
Practice Address - State:IL
Practice Address - Zip Code:62650
Practice Address - Country:US
Practice Address - Phone:217-245-9585
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-11-07
Last Update Date:2023-11-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL043077146164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse