MEDICARE: MRS. LISA MICHELLE JEANSON FNP

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	16232	CA
2	363LF0000X	Family Nurse Practitioner	APRN-3665-0	HI

General Provider Information

NPI Number	:	1831139633
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MRS. LISA MICHELLE JEANSON FNP

Provider Business Mailing Address
First Line	:	PO BOX 6149
Second Line	:
City	:	KAMUELA
State	:	HI
Zip	:	96743-6149
Country	:	US
Telephone Number	:	808-887-6543
Fax Number	:

Provider Business Practice Location Address
First Line	:	75-170 HUALALAI RD STE D214
Second Line	:
City	:	KAILUA KONA
State	:	HI
Zip	:	96740-1780
Country	:	US
Telephone Number	:	808-325-5805
Fax Number	:	86-574-7968

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

Provider Enumeration Date	:	06/08/2006
Last Update Date	:	05/26/2022

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