MEDICARE: LISA MIX RN CCM

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	163WC0400X	Case Management Registered Nurse	4241198	MN
2	163WC0400X	Case Management Registered Nurse	221730-30	WI
3	163WC0400X	Case Management Registered Nurse	R141093-2	MN

General Provider Information

NPI Number	:	1427703578
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	LISA MIX RN CCM

Provider Business Mailing Address
First Line	:	1391 NW 136TH AVE
Second Line	:
City	:	SUNRISE
State	:	FL
Zip	:	33323-2800
Country	:	US
Telephone Number	:	612-400-4652
Fax Number	:

Provider Business Practice Location Address
First Line	:	55 454TH BLVD
Second Line	:
City	:	HARRIS
State	:	MN
Zip	:	55032-4000
Country	:	US
Telephone Number	:	651-334-5671
Fax Number	:

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

Provider Enumeration Date	:	02/17/2022
Last Update Date	:	02/17/2022

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