Healthcare Provider Details

I. General information

NPI: 1710185079
Provider Name (Legal Business Name): LISE MICHELLE MCCANLESS APRN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/10/2007
Last Update Date: 07/01/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8831 IMMOKALEE RD
NAPLES FL
34120-3914
US

IV. Provider business mailing address

380 TERN DR APT 3
NAPLES FL
34112-3922
US

V. Phone/Fax

Practice location:
  • Phone: 757-457-5100
  • Fax: 757-819-7762
Mailing address:
  • Phone: 757-457-5100
  • Fax: 757-819-7762

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number9876
License Number StateVI
# 2
Primary TaxonomyN
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number0024118550
License Number StateVA
# 3
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberARNP9436627
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: