=====================================================
General NPI Number Information
=====================================================
NPI Number | 1346510252
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | LISA RAE WOODRUFF ANP
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/09/2012
-----------------------------------------------------
Last Update Date | 04/19/2023
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 200 MICHIGAN AVE W STE 103
-----------------------------------------------------
City | BATTLE CREEK
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 49017-3632
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 269-598-7488
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 28284 62ND AVE
-----------------------------------------------------
City | LAWTON
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 49065-5613
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 269-547-7630
-----------------------------------------------------
Fax | 269-225-0607
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 363LA2200X
-----------------------------------------------------
Taxonomy Name | Adult Health Nurse Practitioner
-----------------------------------------------------
License Number | 4704253495
-----------------------------------------------------
License Number State | MI
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 363LP0808X
-----------------------------------------------------
Taxonomy Name | Psychiatric/Mental Health Nurse Practitioner
-----------------------------------------------------
License Number | 185256
-----------------------------------------------------
License Number State | AK
-----------------------------------------------------