MEDICARE: MARY MACON LISSNER FNP-C

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	RN234158	GA
2	363LF0000X	Family Nurse Practitioner	272005	AZ
3	363LF0000X	Family Nurse Practitioner	R222059	MD

General Provider Information

NPI Number	:	1811375132
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MARY MACON LISSNER FNP-C

Provider Business Mailing Address
First Line	:	13122 N 103RD ST
Second Line	:
City	:	SCOTTSDALE
State	:	AZ
Zip	:	85260-7200
Country	:	US
Telephone Number	:	404-550-2945
Fax Number	:	706-310-0390

Provider Business Practice Location Address
First Line	:	5259 W INDIAN SCHOOL RD STE 100
Second Line	:
City	:	PHOENIX
State	:	AZ
Zip	:	85031-2651
Country	:	US
Telephone Number	:	623-888-5101
Fax Number	:

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

Provider Enumeration Date	:	05/07/2015
Last Update Date	:	09/15/2024

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