Basic Information
| Provider Information | |||||||||
| NPI: | 1033155726 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | STANLEY | ||||||||
| FirstName: | LISA | ||||||||
| MiddleName: | R | ||||||||
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| Credential: | NP | ||||||||
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| Mailing Information | |||||||||
| Address1: | 7221 ENGLE RD | ||||||||
| Address2: | STE 220 | ||||||||
| City: | FORT WAYNE | ||||||||
| State: | IN | ||||||||
| PostalCode: | 468042233 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2604321568 | ||||||||
| FaxNumber: | 2604324969 | ||||||||
| Practice Location | |||||||||
| Address1: | 5001 US HIGHWAY 30 W STE D | ||||||||
| Address2: | |||||||||
| City: | FORT WAYNE | ||||||||
| State: | IN | ||||||||
| PostalCode: | 468189701 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2604321568 | ||||||||
| FaxNumber: | 2604324969 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/21/2006 | ||||||||
| LastUpdateDate: | 03/10/2020 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 03/10/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LF0000X | 71001366 | IN | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family |
ID Information
| ID | Type | State | Issuer | Description | 200387770 | 05 | IN | MEDICAID |