Healthcare Provider Details

I. General information

NPI: 1790037950
Provider Name (Legal Business Name): LISA A CUNNINGHAM FNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/11/2012
Last Update Date: 08/22/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1605 MARTIN SPRINGS DR STE 250
ROLLA MO
65401-2931
US

IV. Provider business mailing address

PO BOX 2580
SPRINGFIELD MO
65801-2580
US

V. Phone/Fax

Practice location:
  • Phone: 573-458-6363
  • Fax: 573-458-6765
Mailing address:
  • Phone: 417-829-4620
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number2012035124
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: