Healthcare Provider Details

I. General information

NPI: 1174854400
Provider Name (Legal Business Name): LISA MARIE TETZLAFF FNP-C
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: LISA M DAVIDSON FNP-C

II. Dates (important events)

Enumeration Date: 01/27/2010
Last Update Date: 07/16/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

700 NEWBERRY AVE
NEWBERRY MI
49868-1503
US

IV. Provider business mailing address

9789 W BAIRD ST
BRIMLEY MI
49715-9291
US

V. Phone/Fax

Practice location:
  • Phone: 906-293-3226
  • Fax: 877-743-0490
Mailing address:
  • Phone: 906-203-6042
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163WS0200X
TaxonomySchool Registered Nurse
License NumberL1-0037352
License Number StateDE
# 2
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number4704267555
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: