Healthcare Provider Details

I. General information

NPI: 1164761946
Provider Name (Legal Business Name): LISA REQUENA D.O.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/13/2013
Last Update Date: 05/13/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

525 BRANSON LANDING BLVD
BRANSON MO
65616-2052
US

IV. Provider business mailing address

PO BOX 4046
SPRINGFIELD MO
65808-4046
US

V. Phone/Fax

Practice location:
  • Phone: 417-348-8646
  • Fax: 417-335-7529
Mailing address:
  • Phone: 417-269-7241
  • Fax: 417-269-7567

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number2018014210
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: