Provider Demographics
NPI:1366535437
Name:PALAZZOLO, LISA ANN (NP)
Entity type:Individual
Prefix:
First Name:LISA
Middle Name:ANN
Last Name:PALAZZOLO
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7990 E US HIGHWAY 36
Mailing Address - Street 2:
Mailing Address - City:AVON
Mailing Address - State:IN
Mailing Address - Zip Code:46123-7790
Mailing Address - Country:US
Mailing Address - Phone:317-272-0242
Mailing Address - Fax:317-272-7219
Practice Address - Street 1:7990 E US HIGHWAY 36
Practice Address - Street 2:
Practice Address - City:AVON
Practice Address - State:IN
Practice Address - Zip Code:46123-7790
Practice Address - Country:US
Practice Address - Phone:317-272-0242
Practice Address - Fax:317-272-7219
Is Sole Proprietor?:No
Enumeration Date:2006-10-02
Last Update Date:2011-07-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN71001712363L00000X
IN71001712A363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN200509850Medicaid
P00145398Medicare PIN
IN151700VVMedicare PIN
IN200509850Medicaid