Healthcare Provider Details

I. General information

NPI: 1356017446
Provider Name (Legal Business Name): LISA PATRICK
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/18/2021
Last Update Date: 08/18/2021
Certification Date: 08/18/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

515 N 162ND AVE STE 102
OMAHA NE
68118-2540
US

IV. Provider business mailing address

16533 TIMBERLANE DR
OMAHA NE
68136-3077
US

V. Phone/Fax

Practice location:
  • Phone: 402-397-6600
  • Fax:
Mailing address:
  • Phone: 308-940-0132
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163WW0101X
TaxonomyAmbulatory Women's Health Care Registered Nurse
License Number68469
License Number StateNE
# 2
Primary TaxonomyY
Taxonomy Code363LW0102X
TaxonomyWomen's Health Nurse Practitioner
License Number113700
License Number StateNE

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: