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General NPI Number Information
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NPI Number | 1346356524
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Entity Type | Individual
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Provider Name | CATHY DIANE LISENBY PA-C
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Gender | Female
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Dates
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Enumeration Date | 08/21/2006
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Last Update Date | 12/18/2020
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Provider Practice Location Address
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Address Line | 2 GOOD SAMARITAN WAY
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City | MOUNT VERNON
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State | IL
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Zip | 62864-2408
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Country | US
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Telephone | 618-899-4000
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Fax | 618-899-4790
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Provider Business Mailing Address
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Address Line | 5100 LAKE TER NE STE WC
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City | MOUNT VERNON
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State | IL
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Zip | 62864-9665
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Country | US
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Telephone | 618-899-5001
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Fax | 618-242-5152
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 363A00000X
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Taxonomy Name | Physician Assistant
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License Number | 0850001397
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License Number State | IL
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