Provider Demographics
NPI:1992743884
Name:DORNICK, LISA BERNTSON (PNP)
Entity type:Individual
Prefix:
First Name:LISA
Middle Name:BERNTSON
Last Name:DORNICK
Suffix:
Gender:F
Credentials:PNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:250 S 4TH ST
Mailing Address - Street 2:ROOM 250
Mailing Address - City:MINNEAPOLIS
Mailing Address - State:MN
Mailing Address - Zip Code:55415-1384
Mailing Address - Country:US
Mailing Address - Phone:612-673-2301
Mailing Address - Fax:612-673-3866
Practice Address - Street 1:250 S 4TH ST
Practice Address - Street 2:
Practice Address - City:MINNEAPOLIS
Practice Address - State:MN
Practice Address - Zip Code:55415-1384
Practice Address - Country:US
Practice Address - Phone:612-673-2301
Practice Address - Fax:612-673-3866
Is Sole Proprietor?:No
Enumeration Date:2006-06-03
Last Update Date:2012-09-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNR-101808-8363LP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN782314200Medicaid
MN782314200Medicaid
MNP07086Medicare UPIN