Healthcare Provider Details

I. General information

NPI: 1700308558
Provider Name (Legal Business Name): LISA ANN BOURQUIN FNP-APNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: MS. LISA ANN BYRO

II. Dates (important events)

Enumeration Date: 07/13/2017
Last Update Date: 01/18/2024
Certification Date: 01/18/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1 MEDICAL CENTER DR
GALENA IL
61036-8118
US

IV. Provider business mailing address

800 CLAY ST
DARLINGTON WI
53530-1228
US

V. Phone/Fax

Practice location:
  • Phone: 815-777-1340
  • Fax:
Mailing address:
  • Phone: 608-776-3614
  • Fax: 608-776-2317

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number77653-33
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: