Provider Demographics
NPI:1063878288
Name:HAVICK, LISA (AGACNP)
Entity type:Individual
Prefix:
First Name:LISA
Middle Name:
Last Name:HAVICK
Suffix:
Gender:F
Credentials:AGACNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3500 GASTON AVE
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75246-2088
Mailing Address - Country:US
Mailing Address - Phone:214-820-0111
Mailing Address - Fax:
Practice Address - Street 1:3500 GASTON AVE
Practice Address - Street 2:
Practice Address - City:DALLAS
Practice Address - State:TX
Practice Address - Zip Code:75246
Practice Address - Country:US
Practice Address - Phone:214-820-0111
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-01-04
Last Update Date:2019-11-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXAP129579363LA2100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2100XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAcute Care