Healthcare Provider Details

I. General information

NPI: 1083078349
Provider Name (Legal Business Name): LISA MARIE LAND NP-C, ACNPC-AG
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: MS. LISA MARIE SIMES

II. Dates (important events)

Enumeration Date: 04/12/2016
Last Update Date: 01/27/2023
Certification Date: 01/27/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1739 E BEVERLY AVE SUITE 203
KINGMAN AZ
86409-3593
US

IV. Provider business mailing address

1739 E BEVERLY AVE SUITE 203
KINGMAN AZ
86409-3593
US

V. Phone/Fax

Practice location:
  • Phone: 928-757-3133
  • Fax:
Mailing address:
  • Phone: 928-757-3133
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License NumberAP8621
License Number StateAZ
# 2
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberAP8621
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: