Provider Demographics
NPI:1427703578
Name:MIX, LISA (RN CCM)
Entity type:Individual
Prefix:
First Name:LISA
Middle Name:
Last Name:MIX
Suffix:
Gender:F
Credentials:RN CCM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1391 NW 136TH AVE
Mailing Address - Street 2:
Mailing Address - City:SUNRISE
Mailing Address - State:FL
Mailing Address - Zip Code:33323-2800
Mailing Address - Country:US
Mailing Address - Phone:612-400-4652
Mailing Address - Fax:
Practice Address - Street 1:55 454TH BLVD
Practice Address - Street 2:
Practice Address - City:HARRIS
Practice Address - State:MN
Practice Address - Zip Code:55032-4000
Practice Address - Country:US
Practice Address - Phone:651-334-5671
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-02-17
Last Update Date:2022-02-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN4241198163WC0400X
WI221730-30163WC0400X
MNR141093-2163WC0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WC0400XNursing Service ProvidersRegistered NurseCase Management