Provider Demographics
NPI:1962799395
Name:WHITE, LISA MARIE (NP)
Entity type:Individual
Prefix:
First Name:LISA
Middle Name:MARIE
Last Name:WHITE
Suffix:
Gender:
Credentials:NP
Other - Prefix:
Other - First Name:LISA
Other - Middle Name:MARIE
Other - Last Name:KATES
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:RN
Mailing Address - Street 1:6626 E 75TH ST
Mailing Address - Street 2:STE 500
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46250-2805
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:7979 N SHADELAND AVE STE 310
Practice Address - Street 2:
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46250-2042
Practice Address - Country:US
Practice Address - Phone:317-621-3891
Practice Address - Fax:317-621-3893
Is Sole Proprietor?:No
Enumeration Date:2011-07-06
Last Update Date:2025-04-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN28185844A163W00000X
IN71003733A363LA2100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2100XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAcute Care
No163W00000XNursing Service ProvidersRegistered Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
INP01824831OtherRR MEDICARE
IN201108780Medicaid
IN266180930Medicare PIN
INP01824831OtherRR MEDICARE