Basic Information
| Provider Information | |||||||||
| NPI: | 1902867427 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MIKLES | ||||||||
| FirstName: | LISA | ||||||||
| MiddleName: | M | ||||||||
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| Credential: | CRNP | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 21182 | ||||||||
| Address2: | |||||||||
| City: | BALTIMORE | ||||||||
| State: | MD | ||||||||
| PostalCode: | 21228 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4103688640 | ||||||||
| FaxNumber: | 4103688644 | ||||||||
| Practice Location | |||||||||
| Address1: | 8945 GUILFORD RD | ||||||||
| Address2: | SUITE 100 | ||||||||
| City: | COLUMBIA | ||||||||
| State: | MD | ||||||||
| PostalCode: | 210462659 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4109978444 | ||||||||
| FaxNumber: | 4109978832 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/01/2006 | ||||||||
| LastUpdateDate: | 08/09/2016 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363L00000X | R071359 | MD | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner |
ID Information
| ID | Type | State | Issuer | Description | 0025 | 01 | MD | CAREFIRST-DC | OTHER | 525683-02 | 01 | MD | CAREFIRST-MD | OTHER |