Healthcare Provider Details

I. General information

NPI: 1962692756
Provider Name (Legal Business Name): LISA CHARLINA WILLHITE LPN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/27/2007
Last Update Date: 07/27/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

16750 W GARFIELD ST
GOODYEAR AZ
85338-6287
US

IV. Provider business mailing address

16750 W GARFIELD ST
GOODYEAR AZ
85338-6287
US

V. Phone/Fax

Practice location:
  • Phone: 623-772-4710
  • Fax: 623-772-4720
Mailing address:
  • Phone: 623-772-4710
  • Fax: 623-772-4720

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code164W00000X
TaxonomyLicensed Practical Nurse
License NumberLP028098
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: