Provider Demographics
NPI:1962197343
Name:MACIAS, LISA SOUL (DNP, FNP, RN)
Entity type:Individual
Prefix:DR
First Name:LISA
Middle Name:SOUL
Last Name:MACIAS
Suffix:
Gender:F
Credentials:DNP, FNP, RN
Other - Prefix:
Other - First Name:LISA
Other - Middle Name:SOUL
Other - Last Name:LEE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:11262 CAMPUS ST
Mailing Address - Street 2:
Mailing Address - City:LOMA LINDA
Mailing Address - State:CA
Mailing Address - Zip Code:92350-1727
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:27800 MEDICAL CENTER RD STE 110
Practice Address - Street 2:
Practice Address - City:MISSION VIEJO
Practice Address - State:CA
Practice Address - Zip Code:92691-6407
Practice Address - Country:US
Practice Address - Phone:949-866-3600
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-04-10
Last Update Date:2024-07-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA95201564163WC0200X
CA95030923363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No163WC0200XNursing Service ProvidersRegistered NurseCritical Care Medicine