Provider Demographics
NPI:1649261132
Name:CALLAHAN, LISA MICHELLE (RN, MSN, CPNP-PC)
Entity type:Individual
Prefix:MRS
First Name:LISA
Middle Name:MICHELLE
Last Name:CALLAHAN
Suffix:
Gender:F
Credentials:RN, MSN, CPNP-PC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1601 NE 6TH ST
Mailing Address - Street 2:
Mailing Address - City:GRANTS PASS
Mailing Address - State:OR
Mailing Address - Zip Code:97526-1035
Mailing Address - Country:US
Mailing Address - Phone:541-472-0021
Mailing Address - Fax:541-476-4003
Practice Address - Street 1:1601 NE 6TH ST
Practice Address - Street 2:
Practice Address - City:GRANTS PASS
Practice Address - State:OR
Practice Address - Zip Code:97526-1035
Practice Address - Country:US
Practice Address - Phone:541-472-0021
Practice Address - Fax:541-476-4003
Is Sole Proprietor?:Yes
Enumeration Date:2005-11-02
Last Update Date:2016-10-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR94000382363LP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR080965Medicaid
OR106544Medicare ID - Type Unspecified
ORP01681Medicare UPIN