Provider Demographics
NPI:1083699771
Name:KOHLER, LISA MARIE (ARNP)
Entity type:Individual
Prefix:MS
First Name:LISA
Middle Name:MARIE
Last Name:KOHLER
Suffix:
Gender:F
Credentials:ARNP
Other - Prefix:
Other - First Name:MARIE
Other - Middle Name:E
Other - Last Name:FREDERICK
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:ARNP
Mailing Address - Street 1:1400 E KINCAID ST
Mailing Address - Street 2:ATTN: CREDENTIALING
Mailing Address - City:MOUNT VERNON
Mailing Address - State:WA
Mailing Address - Zip Code:98274-4127
Mailing Address - Country:US
Mailing Address - Phone:360-428-2500
Mailing Address - Fax:360-428-6485
Practice Address - Street 1:1400 E KINCAID ST
Practice Address - Street 2:
Practice Address - City:MOUNT VERNON
Practice Address - State:WA
Practice Address - Zip Code:98274-4127
Practice Address - Country:US
Practice Address - Phone:360-428-6434
Practice Address - Fax:360-848-4233
Is Sole Proprietor?:No
Enumeration Date:2005-12-14
Last Update Date:2015-07-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAAP30007703363LF0000X, 363LA2100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No363LA2100XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAcute Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA3169FROtherBSWA
WA1042213Medicaid
WA0220034OtherLIWA
WA9652330Medicaid
WAP00424141Medicare PIN
WAS82316Medicare PIN
WA1042213Medicaid