MEDICARE: MRS. LISA MARIE LANCE R.N.

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	163W00000X	Registered Nurse	626812	TX

General Provider Information

NPI Number	:	1598091787
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MRS. LISA MARIE LANCE R.N.

Provider Business Mailing Address
First Line	:	3048 HULEN ST.
Second Line	:
City	:	FORT WORTH
State	:	TX
Zip	:	76107
Country	:	US
Telephone Number	:	817-688-3230
Fax Number	:	817-569-5249

Provider Business Practice Location Address
First Line	:	1200 CIRCLE DR
Second Line	:	101
City	:	FORT WORTH
State	:	TX
Zip	:	76119-8112
Country	:	US
Telephone Number	:	817-688-3230
Fax Number	:	817-569-5249

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

Provider Enumeration Date	:	10/23/2009
Last Update Date	:	10/23/2009

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