Healthcare Provider Details

I. General information

NPI: 1578813317
Provider Name (Legal Business Name): LISA LYNNE STABILE FNP-BC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/19/2012
Last Update Date: 09/19/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

560 W MITCHELL ST SUIT M-40
PETOSKEY MI
49770-2275
US

IV. Provider business mailing address

560 W MITCHELL ST SUIT M-40
PETOSKEY MI
49770-2275
US

V. Phone/Fax

Practice location:
  • Phone: 231-487-2391
  • Fax: 231-487-6513
Mailing address:
  • Phone: 231-487-2391
  • Fax: 231-487-6513

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number4704239627
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: