Provider Demographics
NPI:1396285714
Name:LISA HISSONG
Entity type:Organization
Organization Name:LISA HISSONG
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:LPN
Authorized Official - Prefix:
Authorized Official - First Name:LISA
Authorized Official - Middle Name:MARIE
Authorized Official - Last Name:HISSONG
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:337-301-1272
Mailing Address - Street 1:949 GUCKERT AVE
Mailing Address - Street 2:
Mailing Address - City:NEWARK
Mailing Address - State:OH
Mailing Address - Zip Code:43055-2635
Mailing Address - Country:US
Mailing Address - Phone:337-301-1272
Mailing Address - Fax:
Practice Address - Street 1:949 GUCKERT AVE
Practice Address - Street 2:
Practice Address - City:NEWARK
Practice Address - State:OH
Practice Address - Zip Code:43055-2635
Practice Address - Country:US
Practice Address - Phone:337-301-1272
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-03-04
Last Update Date:2017-03-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes305R00000XManaged Care OrganizationsPreferred Provider Organization