Provider Demographics
NPI:1093838963
Name:LUBBERS, LISA ANNETTE (CNP)
Entity type:Individual
Prefix:
First Name:LISA
Middle Name:ANNETTE
Last Name:LUBBERS
Suffix:
Gender:F
Credentials:CNP
Other - Prefix:
Other - First Name:LISA
Other - Middle Name:ANNETTE
Other - Last Name:ROLLING
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:8170 33RD AVE S # MS 21110Q
Mailing Address - Street 2:
Mailing Address - City:BLOOMINGTON
Mailing Address - State:MN
Mailing Address - Zip Code:55425-4516
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:6500 EXCELSIOR BLVD
Practice Address - Street 2:
Practice Address - City:ST LOUIS PARK
Practice Address - State:MN
Practice Address - Zip Code:55426-4702
Practice Address - Country:US
Practice Address - Phone:952-993-5000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-04-07
Last Update Date:2024-05-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNR160724-0363LN0000X
MNCNP1136363L00000X
SDCP000374363LN0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No363LN0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerNeonatal
Provider Identifiers
StateIdentifier IDID TypeIssuer
MNR 160724-0OtherMN RN
SDR0287659OtherRN LICENSE
SDLUB1-0430-2308OtherNCC ID
SD6829300Medicaid
SD9254403OtherDAKOTACARE
SD4993173OtherWELLMARK
SDCP000374OtherCNP LICENSE