Healthcare Provider Details

I. General information

NPI: 1790091205
Provider Name (Legal Business Name): LISA A GEORGE APRN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: LISA A MULLEN APRN

II. Dates (important events)

Enumeration Date: 08/20/2010
Last Update Date: 10/07/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2602 J ST
OMAHA NE
68107-1643
US

IV. Provider business mailing address

2602 J ST
OMAHA NE
68107-1643
US

V. Phone/Fax

Practice location:
  • Phone: 402-733-3612
  • Fax: 402-733-3487
Mailing address:
  • Phone: 402-733-3612
  • Fax: 402-733-3487

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number111150
License Number StateNE

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: