Provider Demographics
NPI:1336772771
Name:JOHNSON, LISA M
Entity Type:Individual
Prefix:
First Name:LISA
Middle Name:M
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:LISA
Other - Middle Name:M
Other - Last Name:YECKLEY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:11838 E 166TH ST N
Mailing Address - Street 2:
Mailing Address - City:COLLINSVILLE
Mailing Address - State:OK
Mailing Address - Zip Code:74021-4537
Mailing Address - Country:US
Mailing Address - Phone:918-808-1096
Mailing Address - Fax:
Practice Address - Street 1:3400 E FRANK PHILLIPS BLVD STE 501
Practice Address - Street 2:
Practice Address - City:BARTLESVILLE
Practice Address - State:OK
Practice Address - Zip Code:74006-2405
Practice Address - Country:US
Practice Address - Phone:918-331-2415
Practice Address - Fax:918-331-2551
Is Sole Proprietor?:No
Enumeration Date:2020-02-13
Last Update Date:2024-03-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK116093363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner