Provider Demographics
NPI:1154408110
Name:WHITE, LISA NIELSEN (DPT)
Entity type:Individual
Prefix:
First Name:LISA
Middle Name:NIELSEN
Last Name:WHITE
Suffix:
Gender:F
Credentials:DPT
Other - Prefix:
Other - First Name:LISA
Other - Middle Name:M
Other - Last Name:NIELSEN-WHITE
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:PT, DPT
Mailing Address - Street 1:14439 275TH ST
Mailing Address - Street 2:
Mailing Address - City:TREYNOR
Mailing Address - State:IA
Mailing Address - Zip Code:51575-7266
Mailing Address - Country:US
Mailing Address - Phone:402-965-1670
Mailing Address - Fax:
Practice Address - Street 1:14439 275TH ST
Practice Address - Street 2:
Practice Address - City:TREYNOR
Practice Address - State:IA
Practice Address - Zip Code:51575-7266
Practice Address - Country:US
Practice Address - Phone:402-670-3819
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-01
Last Update Date:2021-03-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE1671225100000X
IA03738225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA0478800Medicaid
NE10025288900Medicaid
NE10025288900Medicaid