Provider Demographics
NPI:1124405873
Name:GILLETTE, LISA FARRER
Entity type:Individual
Prefix:
First Name:LISA
Middle Name:FARRER
Last Name:GILLETTE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:LISA
Other - Middle Name:FARRER
Other - Last Name:MESCHAN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:10042 MULBERRY LN
Mailing Address - Street 2:
Mailing Address - City:GRAND BLANC
Mailing Address - State:MI
Mailing Address - Zip Code:48439-2535
Mailing Address - Country:US
Mailing Address - Phone:989-513-0972
Mailing Address - Fax:
Practice Address - Street 1:10042 MULBERRY LN
Practice Address - Street 2:
Practice Address - City:GRAND BLANC
Practice Address - State:MI
Practice Address - Zip Code:48439-2535
Practice Address - Country:US
Practice Address - Phone:989-513-0935
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-05-01
Last Update Date:2019-03-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes247200000XTechnologists, Technicians & Other Technical Service ProvidersTechnician, Other
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI1124405873Medicaid