Healthcare Provider Details

I. General information

NPI: 1922408327
Provider Name (Legal Business Name): LISA NICOLE CHICA RN, CNP, PMHNP
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/04/2014
Last Update Date: 08/26/2020
Certification Date: 08/26/2020
Deactivation Date: 08/19/2020
Reactivation Date: 08/26/2020

III. Provider practice location address

1642 S PRIEST DR
TEMPE AZ
85281-6204
US

IV. Provider business mailing address

1642 S PRIEST DR
TEMPE AZ
85281-6204
US

V. Phone/Fax

Practice location:
  • Phone: 631-428-4999
  • Fax:
Mailing address:
  • Phone: 631-428-4999
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number230421
License Number StateAZ
# 2
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number689339
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: