Healthcare Provider Details

I. General information

NPI: 1609799188
Provider Name (Legal Business Name): LISA THI LERTIQUE FNP-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/03/2026
Last Update Date: 08/03/2026
Certification Date: 08/02/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

687 W JUANITA AVE
GILBERT AZ
85233-2626
US

IV. Provider business mailing address

687 W JUANITA AVE
GILBERT AZ
85233-2626
US

V. Phone/Fax

Practice location:
  • Phone: 480-234-7442
  • Fax:
Mailing address:
  • Phone: 480-234-7442
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number300447
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: