Provider Demographics
NPI:1962110429
Name:WANGBERG, LISA MARIE (FNP/DNP)
Entity type:Individual
Prefix:
First Name:LISA
Middle Name:MARIE
Last Name:WANGBERG
Suffix:
Gender:F
Credentials:FNP/DNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:303 VALLEYWOOD DR
Mailing Address - Street 2:
Mailing Address - City:FOREST
Mailing Address - State:VA
Mailing Address - Zip Code:24551-2809
Mailing Address - Country:US
Mailing Address - Phone:907-775-2407
Mailing Address - Fax:
Practice Address - Street 1:1505 FRANKLIN RD SW
Practice Address - Street 2:
Practice Address - City:ROANOKE
Practice Address - State:VA
Practice Address - Zip Code:24016-5206
Practice Address - Country:US
Practice Address - Phone:540-343-7331
Practice Address - Fax:540-343-7349
Is Sole Proprietor?:Yes
Enumeration Date:2022-11-14
Last Update Date:2022-11-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0024185593363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily