Healthcare Provider Details

I. General information

NPI: 1790315265
Provider Name (Legal Business Name): LISA MARIE MCMILLAN NP
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/23/2020
Last Update Date: 01/23/2020
Certification Date: 01/23/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

331 W 4TH ST
CINCINNATI OH
45202-2713
US

IV. Provider business mailing address

1351 DELTA AVE
CINCINNATI OH
45208-2444
US

V. Phone/Fax

Practice location:
  • Phone: 513-675-7111
  • Fax:
Mailing address:
  • Phone: 513-675-7111
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WW0101X
TaxonomyAmbulatory Women's Health Care Registered Nurse
License NumberAPRN.CNP.03823
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: