Provider Demographics
NPI:1295800290
Name:HINCKLEY, LISA A (RN)
Entity type:Individual
Prefix:
First Name:LISA
Middle Name:A
Last Name:HINCKLEY
Suffix:
Gender:F
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:294 N 400 E
Mailing Address - Street 2:
Mailing Address - City:LINDON
Mailing Address - State:UT
Mailing Address - Zip Code:84042-1515
Mailing Address - Country:US
Mailing Address - Phone:801-796-3548
Mailing Address - Fax:
Practice Address - Street 1:151 S UNIVERSITY AVE # 1900
Practice Address - Street 2:
Practice Address - City:PROVO
Practice Address - State:UT
Practice Address - Zip Code:84601-4427
Practice Address - Country:US
Practice Address - Phone:801-851-7061
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-11-22
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT265470-3102163WC1500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WC1500XNursing Service ProvidersRegistered NurseCommunity Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
UT103003506102OtherSELECT HEALTH PROVIDER #
UTPR00489Medicaid
UT55102OtherPEHP PROVIDER#
UTQM0000039389OtherALTIUS PROVIDER#
UT73-00012OtherUNITED HEALTHCARE #
UT998877660009Medicaid