Healthcare Provider Details

I. General information

NPI: 1760673404
Provider Name (Legal Business Name): LISA MARIE KINSEY FNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/07/2007
Last Update Date: 08/07/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12647 OLIVE BLVD STE 600
SAINT LOUIS MO
63141-6346
US

IV. Provider business mailing address

4760 CHESNEY MEADOWS DR
STRAWBERRY PLAINS TN
37871-1673
US

V. Phone/Fax

Practice location:
  • Phone: 800-325-3982
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number0000012737
License Number StateTN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: