Healthcare Provider Details

I. General information

NPI: 1922592369
Provider Name (Legal Business Name): LIZA JENNIFER WHITACRE CNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/19/2018
Last Update Date: 08/08/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7443 JACKMAN RD
TEMPERANCE MI
48182
US

IV. Provider business mailing address

6009 MITCHAW RD
SYLVANIA OH
43560-9410
US

V. Phone/Fax

Practice location:
  • Phone: 734-850-0112
  • Fax: 734-850-0100
Mailing address:
  • Phone: 419-494-6638
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number4704345718
License Number StateMI
# 2
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberAPRN.CNP.02265
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: