Provider Demographics
NPI:1992166490
Name:MOELLERING, LISA (RN, CPNP-PC)
Entity type:Individual
Prefix:
First Name:LISA
Middle Name:
Last Name:MOELLERING
Suffix:
Gender:
Credentials:RN, CPNP-PC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3919 W JEFFERSON BLVD
Mailing Address - Street 2:
Mailing Address - City:FORT WAYNE
Mailing Address - State:IN
Mailing Address - Zip Code:46804-6811
Mailing Address - Country:US
Mailing Address - Phone:260-436-7722
Mailing Address - Fax:260-459-0012
Practice Address - Street 1:3919 W JEFFERSON BLVD
Practice Address - Street 2:
Practice Address - City:FORT WAYNE
Practice Address - State:IN
Practice Address - Zip Code:46804-6811
Practice Address - Country:US
Practice Address - Phone:832-482-8518
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-03-10
Last Update Date:2025-04-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN28144452A363LP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN1275546913Medicaid