Healthcare Provider Details

I. General information

NPI: 1497748263
Provider Name (Legal Business Name): LISA RAE GERGEN APRN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: LISA R. SIRONEN NP

II. Dates (important events)

Enumeration Date: 08/26/2005
Last Update Date: 02/03/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

560 S LOOP RD
EDGEWOOD KY
41017-3405
US

IV. Provider business mailing address

560 S LOOP RD
EDGEWOOD KY
41017-3405
US

V. Phone/Fax

Practice location:
  • Phone: 859-301-2663
  • Fax: 859-301-0655
Mailing address:
  • Phone: 859-301-2663
  • Fax: 859-301-0655

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberRN-232372
License Number StateOH
# 2
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number1067394
License Number StateKY
# 3
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number3003813
License Number StateKY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: