MEDICARE: LISALYNN, LLC

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	363LP0808X	Psychiatric/Mental Health Nurse Practitioner

General Provider Information

NPI Number	:	1871268904
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	LISALYNN, LLC

Provider Business Mailing Address
First Line	:	967 TREASURE LK
Second Line	:
City	:	DU BOIS
State	:	PA
Zip	:	15801-9022
Country	:	US
Telephone Number	:	308-520-2988
Fax Number	:

Provider Business Practice Location Address
First Line	:	1912 BAY RD
Second Line	:
City	:	DUBOIS
State	:	PA
Zip	:	15801
Country	:	US
Telephone Number	:	308-520-2988
Fax Number	:

Authorized Official
Title or Position	:	OWNER
Name	:	LISA LYNN HENGEN
Credential	:	DNP
Telephone Number	:	308-520-2988

Provider Enumeration Date	:	08/11/2021
Last Update Date	:	09/07/2023

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