Provider Demographics
NPI:1811375132
Name:LISSNER, MARY MACON (FNP-C)
Entity type:Individual
Prefix:
First Name:MARY MACON
Middle Name:
Last Name:LISSNER
Suffix:
Gender:F
Credentials:FNP-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:13122 N 103RD ST
Mailing Address - Street 2:
Mailing Address - City:SCOTTSDALE
Mailing Address - State:AZ
Mailing Address - Zip Code:85260-7200
Mailing Address - Country:US
Mailing Address - Phone:404-550-2945
Mailing Address - Fax:706-310-0390
Practice Address - Street 1:5259 W INDIAN SCHOOL RD STE 100
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85031-2651
Practice Address - Country:US
Practice Address - Phone:623-888-5101
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-05-07
Last Update Date:2024-09-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARN234158363LF0000X
AZ272005363LF0000X
MDR222059363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily