Provider Demographics
NPI:1750912457
Name:BIENFANG, LISA
Entity type:Individual
Prefix:
First Name:LISA
Middle Name:
Last Name:BIENFANG
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:22712 N AVE
Mailing Address - Street 2:
Mailing Address - City:GRUNDY CENTER
Mailing Address - State:IA
Mailing Address - Zip Code:50638-8520
Mailing Address - Country:US
Mailing Address - Phone:641-751-4377
Mailing Address - Fax:
Practice Address - Street 1:22712 N AVE
Practice Address - Street 2:
Practice Address - City:GRUNDY CENTER
Practice Address - State:IA
Practice Address - Zip Code:50638-8520
Practice Address - Country:US
Practice Address - Phone:641-751-4377
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-01-31
Last Update Date:2020-01-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
372600000X, 374U00000X, 376J00000X
IA184GG2144172A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172A00000XOther Service ProvidersDriver
No372600000XNursing Service Related ProvidersAdult Companion
No374U00000XNursing Service Related ProvidersHome Health Aide
No376J00000XNursing Service Related ProvidersHomemaker