Provider Demographics
NPI:1669816104
Name:WHEATON, LISA (RN)
Entity type:Individual
Prefix:MS
First Name:LISA
Middle Name:
Last Name:WHEATON
Suffix:
Gender:F
Credentials:RN
Other - Prefix:MRS
Other - First Name:LISA
Other - Middle Name:
Other - Last Name:PROEBSTEL
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1963 SNEFFELS ST
Mailing Address - Street 2:
Mailing Address - City:MONTROSE
Mailing Address - State:CO
Mailing Address - Zip Code:81401-6451
Mailing Address - Country:US
Mailing Address - Phone:269-757-1020
Mailing Address - Fax:
Practice Address - Street 1:70 STAFFORD LN
Practice Address - Street 2:
Practice Address - City:DELTA
Practice Address - State:CO
Practice Address - Zip Code:81416-2282
Practice Address - Country:US
Practice Address - Phone:269-757-1020
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-04-27
Last Update Date:2013-04-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4704260397163WE0003X
WI165123-030163WE0003X
CORN0204139163WH0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WE0003XNursing Service ProvidersRegistered NurseEmergency
No163WH0200XNursing Service ProvidersRegistered NurseHome Health