Healthcare Provider Details

I. General information

NPI: 1053645770
Provider Name (Legal Business Name): LISA MARIE MRZENA APRN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: LISA MARIE THOMPSON MHPNP-BC

II. Dates (important events)

Enumeration Date: 09/28/2009
Last Update Date: 10/17/2024
Certification Date: 10/17/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

290 N WILLOW ST
WASILLA AK
99654-7042
US

IV. Provider business mailing address

PO BOX 876023
WASILLA AK
99687-6023
US

V. Phone/Fax

Practice location:
  • Phone: 435-703-9647
  • Fax:
Mailing address:
  • Phone: 907-203-1590
  • Fax: 435-359-9580

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number130269
License Number StateAK
# 2
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number6593775-3102
License Number StateUT
# 3
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number6593775-3102
License Number StateUT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: