Provider Demographics
NPI:1124096151
Name:GRUMMER, LISA M (APN)
Entity type:Individual
Prefix:
First Name:LISA
Middle Name:M
Last Name:GRUMMER
Suffix:
Gender:F
Credentials:APN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:1 LILE CT
Mailing Address - Street 2:SUTE 200
Mailing Address - City:LITTLE ROCK
Mailing Address - State:AR
Mailing Address - Zip Code:72205-6242
Mailing Address - Country:US
Mailing Address - Phone:501-224-5500
Mailing Address - Fax:501-224-1166
Practice Address - Street 1:1 LILE CT
Practice Address - Street 2:SUITE 200
Practice Address - City:LITTLE ROCK
Practice Address - State:AR
Practice Address - Zip Code:72205-6242
Practice Address - Country:US
Practice Address - Phone:501-224-5500
Practice Address - Fax:501-224-1166
Is Sole Proprietor?:No
Enumeration Date:2006-03-08
Last Update Date:2012-01-26
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
ARP01739363LX0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LX0001XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR5U655Medicare PIN
5988047069Medicare PIN
ARS98804Medicare UPIN
5U655Medicare ID - Type Unspecified
AR5U6557069Medicare PIN