MEDICARE: MISS LISA MAE MANCHESTER APRN

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	363LF0000X	Family Nurse Practitioner	111261	NE
2	163WG0000X	General Practice Registered Nurse	66171	NE

General Provider Information

NPI Number	:	1033490297
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MISS LISA MAE MANCHESTER APRN

Provider Business Mailing Address
First Line	:	15905 W DODGE RD
Second Line	:	APT. 3D
City	:	OMAHA
State	:	NE
Zip	:	68118-4032
Country	:	US
Telephone Number	:	402-719-4329
Fax Number	:

Provider Business Practice Location Address
First Line	:	425 N DIERS AVE
Second Line	:
City	:	GRAND ISLAND
State	:	NE
Zip	:	68803-4910
Country	:	US
Telephone Number	:	308-389-3278
Fax Number	:	308-382-1149

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	09/01/2011
Last Update Date	:	12/09/2016

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