Healthcare Provider Details

I. General information

NPI: 1700196888
Provider Name (Legal Business Name): LISA MARIE MCCONNELL FNP-BC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: LISA MARIE NELSON FNP-BC

II. Dates (important events)

Enumeration Date: 10/07/2010
Last Update Date: 03/26/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2751 RESEARCH PARK DR
SOQUEL CA
95073-2037
US

IV. Provider business mailing address

2350 W EL CAMINO REAL FL 2
MOUNTAIN VIEW CA
94040-6203
US

V. Phone/Fax

Practice location:
  • Phone: 800-972-5547
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number4704161913
License Number StateMI
# 2
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number14114
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: