Provider Demographics
NPI:1336820505
Name:WEATHERWAX, LISA (MSN, ARNP, PMHNP-BC)
Entity Type:Individual
Prefix:
First Name:LISA
Middle Name:
Last Name:WEATHERWAX
Suffix:
Gender:F
Credentials:MSN, ARNP, PMHNP-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5000 WESTOWN PKWY STE 104
Mailing Address - Street 2:
Mailing Address - City:WEST DES MOINES
Mailing Address - State:IA
Mailing Address - Zip Code:50266-5936
Mailing Address - Country:US
Mailing Address - Phone:515-679-3947
Mailing Address - Fax:515-349-5301
Practice Address - Street 1:5000 WESTOWN PKWY STE 104
Practice Address - Street 2:
Practice Address - City:WEST DES MOINES
Practice Address - State:IA
Practice Address - Zip Code:50266-5936
Practice Address - Country:US
Practice Address - Phone:515-679-3947
Practice Address - Fax:515-349-5301
Is Sole Proprietor?:No
Enumeration Date:2023-07-31
Last Update Date:2023-07-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IAG175623363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health