Healthcare Provider Details

I. General information

NPI: 1063447753
Provider Name (Legal Business Name): LISA N PIPER MD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: LISA N BOOTH

II. Dates (important events)

Enumeration Date: 07/11/2006
Last Update Date: 03/21/2023
Certification Date: 03/21/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

207 N TOWNLINE RD STE 104
LAGRANGE IN
46761-1325
US

IV. Provider business mailing address

11109 PARKVIEW PLAZA DR # 117
FORT WAYNE IN
46845-1701
US

V. Phone/Fax

Practice location:
  • Phone: 260-463-9360
  • Fax: 260-463-9374
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number01041550A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: