Healthcare Provider Details

I. General information

NPI: 1700123973
Provider Name (Legal Business Name): AMY LYNN LISDAHL PMHNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/08/2013
Last Update Date: 04/22/2025
Certification Date: 04/22/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

810 E 4TH ST
DULUTH MN
55805-2147
US

IV. Provider business mailing address

1900 SILVER LAKE RD NW
NEW BRIGHTON MN
55112-1786
US

V. Phone/Fax

Practice location:
  • Phone: 218-728-4491
  • Fax: 218-730-2367
Mailing address:
  • Phone: 651-628-9566
  • Fax: 651-628-0411

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number606806
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License NumberCNP4944
License Number StateMN
# 3
Primary TaxonomyN
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number95002695
License Number StateCA
# 4
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number7410
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: