Provider Demographics
NPI:1588931059
Name:YACOUB, LISA (NP-C)
Entity type:Individual
Prefix:MRS
First Name:LISA
Middle Name:
Last Name:YACOUB
Suffix:
Gender:F
Credentials:NP-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:38377 MOUNT KISCO DR
Mailing Address - Street 2:
Mailing Address - City:STERLING HEIGHTS
Mailing Address - State:MI
Mailing Address - Zip Code:48310-3426
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:26000 HOOVER RD
Practice Address - Street 2:SUITE 103
Practice Address - City:WARREN
Practice Address - State:MI
Practice Address - Zip Code:48089-1167
Practice Address - Country:US
Practice Address - Phone:586-427-1351
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-11-28
Last Update Date:2011-11-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4704240796363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily