Provider Demographics
NPI:1295152015
Name:MAKARA, LISA (NP)
Entity type:Individual
Prefix:
First Name:LISA
Middle Name:
Last Name:MAKARA
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 1:1485 M 139
Mailing Address - Street 2:
Mailing Address - City:BENTON HARBOR
Mailing Address - State:MI
Mailing Address - Zip Code:49022-5711
Mailing Address - Country:US
Mailing Address - Phone:269-934-1611
Mailing Address - Fax:269-927-1326
Practice Address - Street 1:1485 M 139
Practice Address - Street 2:
Practice Address - City:BENTON HARBOR
Practice Address - State:MI
Practice Address - Zip Code:49022-5711
Practice Address - Country:US
Practice Address - Phone:269-934-1611
Practice Address - Fax:269-927-1326
Is Sole Proprietor?:No
Enumeration Date:2014-03-19
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4704305988363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI1716175Medicaid
MIMM3231622OtherDEA