Provider Demographics
NPI:1841459690
Name:CLOUGH, LISA (FNP)
Entity type:Individual
Prefix:MRS
First Name:LISA
Middle Name:
Last Name:CLOUGH
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 9000
Mailing Address - Street 2:
Mailing Address - City:PUEBLO
Mailing Address - State:CO
Mailing Address - Zip Code:81008-9000
Mailing Address - Country:US
Mailing Address - Phone:719-553-2200
Mailing Address - Fax:719-553-2216
Practice Address - Street 1:3676 PARKER BLVD
Practice Address - Street 2:SUITE 260
Practice Address - City:PUEBLO
Practice Address - State:CO
Practice Address - Zip Code:81008-2212
Practice Address - Country:US
Practice Address - Phone:719-553-2201
Practice Address - Fax:719-553-2224
Is Sole Proprietor?:No
Enumeration Date:2008-06-06
Last Update Date:2008-06-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO5716363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO5716OtherSTATE LISCENSE