Healthcare Provider Details

I. General information

NPI: 1033490297
Provider Name (Legal Business Name): LISA MAE MANCHESTER APRN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/01/2011
Last Update Date: 12/09/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

425 N DIERS AVE
GRAND ISLAND NE
68803-4910
US

IV. Provider business mailing address

15905 W DODGE RD APT. 3D
OMAHA NE
68118-4032
US

V. Phone/Fax

Practice location:
  • Phone: 308-389-3278
  • Fax: 308-382-1149
Mailing address:
  • Phone: 402-719-4329
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number111261
License Number StateNE
# 2
Primary TaxonomyN
Taxonomy Code163WG0000X
TaxonomyGeneral Practice Registered Nurse
License Number66171
License Number StateNE

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: