Provider Demographics
NPI:1457772451
Name:MICKELSON, LISA JENNIFER (RN)
Entity Type:Individual
Prefix:MRS
First Name:LISA
Middle Name:JENNIFER
Last Name:MICKELSON
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 1:8260 WICKER AVE.
Mailing Address - Street 2:LAKE CENTRAL SCHOOL CORPORATION
Mailing Address - City:SAINT JOHN
Mailing Address - State:IN
Mailing Address - Zip Code:46373
Mailing Address - Country:US
Mailing Address - Phone:219-365-8507
Mailing Address - Fax:
Practice Address - Street 1:600 JOLIET ST.
Practice Address - Street 2:KAHLER MIDDLE SCHOOL
Practice Address - City:DYER
Practice Address - State:IN
Practice Address - Zip Code:46311
Practice Address - Country:US
Practice Address - Phone:219-865-3535
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-12-18
Last Update Date:2013-12-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN28153569A163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse