Healthcare Provider Details

I. General information

NPI: 1669816104
Provider Name (Legal Business Name): LISA WHEATON RN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: MRS. LISA PROEBSTEL

II. Dates (important events)

Enumeration Date: 04/27/2013
Last Update Date: 04/27/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

70 STAFFORD LN
DELTA CO
81416-2282
US

IV. Provider business mailing address

1963 SNEFFELS ST
MONTROSE CO
81401-6451
US

V. Phone/Fax

Practice location:
  • Phone: 269-757-1020
  • Fax:
Mailing address:
  • Phone: 269-757-1020
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WE0003X
TaxonomyEmergency Registered Nurse
License Number4704260397
License Number StateMI
# 2
Primary TaxonomyN
Taxonomy Code163WE0003X
TaxonomyEmergency Registered Nurse
License Number165123-030
License Number StateWI
# 3
Primary TaxonomyN
Taxonomy Code163WH0200X
TaxonomyHome Health Registered Nurse
License NumberRN0204139
License Number StateCO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: