Healthcare Provider Details

I. General information

NPI: 1285656801
Provider Name (Legal Business Name): LISA LOUISE KUETTLE FNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/24/2006
Last Update Date: 09/03/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1700 SE TEMPEST DR
BEND OR
97702-1884
US

IV. Provider business mailing address

375 NW BEAVER ST STE 101
PRINEVILLE OR
97754-1802
US

V. Phone/Fax

Practice location:
  • Phone: 541-323-3854
  • Fax: 541-383-1883
Mailing address:
  • Phone: 541-447-0707
  • Fax: 541-383-1883

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number20055078NP
License Number StateOR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: