Provider Demographics
NPI:1780082073
Name:SLOOTMAKER, LISA
Entity type:Individual
Prefix:
First Name:LISA
Middle Name:
Last Name:SLOOTMAKER
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 1:4007 HESS ST
Mailing Address - Street 2:
Mailing Address - City:NORTON SHORES
Mailing Address - State:MI
Mailing Address - Zip Code:49444-3971
Mailing Address - Country:US
Mailing Address - Phone:231-286-6275
Mailing Address - Fax:
Practice Address - Street 1:4007 HESS ST
Practice Address - Street 2:
Practice Address - City:NORTON SHORES
Practice Address - State:MI
Practice Address - Zip Code:49444-3971
Practice Address - Country:US
Practice Address - Phone:231-286-6275
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-12-18
Last Update Date:2014-12-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4703090020164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse