Provider Demographics
NPI:1841408275
Name:ILLG, LISA P (PT)
Entity type:Individual
Prefix:MS
First Name:LISA
Middle Name:P
Last Name:ILLG
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:809 S CHUGACH ST
Mailing Address - Street 2:SUITE 1
Mailing Address - City:PALMER
Mailing Address - State:AK
Mailing Address - Zip Code:99645-6605
Mailing Address - Country:US
Mailing Address - Phone:907-746-4373
Mailing Address - Fax:907-746-4376
Practice Address - Street 1:809 S CHUGACH ST
Practice Address - Street 2:SUITE 1
Practice Address - City:PALMER
Practice Address - State:AK
Practice Address - Zip Code:99645-6605
Practice Address - Country:US
Practice Address - Phone:907-746-4373
Practice Address - Fax:907-746-4376
Is Sole Proprietor?:No
Enumeration Date:2007-05-18
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AKPT1290225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist