Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 363LN0000X | Nurse Practitioner - Neonatal | AP2222 | AZ |
N | 363LN0000X | Nurse Practitioner - Neonatal | RN113958 | AZ |
NPI | 1063503795 |
---|---|
Provider Name | Ms. Lisa M Grisham |
First Address | Tucson, AZ 85756-7214 |
Second Address | Tucson, AZ 85724 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 27/09/2006 |
Last Update Date | 22/05/2013 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
207375 | (05) | AZ |
Q51719 | (02) |