Provider Demographics
NPI:1376781013
Name:GREENACRE, LISA CAROL (WHNP)
Entity type:Individual
Prefix:
First Name:LISA
Middle Name:CAROL
Last Name:GREENACRE
Suffix:
Gender:F
Credentials:WHNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:333 S DESPLAINES ST STE 201
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60661-5514
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:500 BROADWAY STE 7
Practice Address - Street 2:
Practice Address - City:SANTA MONICA
Practice Address - State:CA
Practice Address - Zip Code:90401-2988
Practice Address - Country:US
Practice Address - Phone:323-410-1291
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-02-03
Last Update Date:2024-05-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZAP6444363LW0102X
IL209008024363LW0102X
CA95015648363LW0102X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LW0102XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerWomen's Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL$$$$$$$$$001Medicaid
IL522000018Medicare PIN