Provider Demographics
NPI:1811360092
Name:LISA HIESTAND
Entity type:Organization
Organization Name:LISA HIESTAND
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ARNP-C
Authorized Official - Prefix:MS
Authorized Official - First Name:LISA
Authorized Official - Middle Name:MICHELLE
Authorized Official - Last Name:HIESTAND
Authorized Official - Suffix:
Authorized Official - Credentials:ARNP-C
Authorized Official - Phone:863-844-1636
Mailing Address - Street 1:5929 COLONY PLACE DR
Mailing Address - Street 2:
Mailing Address - City:LAKELAND
Mailing Address - State:FL
Mailing Address - Zip Code:33813-2872
Mailing Address - Country:US
Mailing Address - Phone:863-844-1636
Mailing Address - Fax:
Practice Address - Street 1:5929 COLONY PLACE DR
Practice Address - Street 2:
Practice Address - City:LAKELAND
Practice Address - State:FL
Practice Address - Zip Code:33813-2872
Practice Address - Country:US
Practice Address - Phone:863-844-1636
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-11-10
Last Update Date:2015-11-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL2011842363LP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LP2300XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPrimary CareGroup - Multi-Specialty