Provider Demographics
NPI:1538575998
Name:FERNELIUS, LISA ANN (RN)
Entity type:Individual
Prefix:
First Name:LISA
Middle Name:ANN
Last Name:FERNELIUS
Suffix:
Gender:F
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3045 ENSIGN AVE N
Mailing Address - Street 2:
Mailing Address - City:NEW HOPE
Mailing Address - State:MN
Mailing Address - Zip Code:55427-2424
Mailing Address - Country:US
Mailing Address - Phone:612-423-4194
Mailing Address - Fax:
Practice Address - Street 1:3045 ENSIGN AVE N
Practice Address - Street 2:
Practice Address - City:NEW HOPE
Practice Address - State:MN
Practice Address - Zip Code:55427-2424
Practice Address - Country:US
Practice Address - Phone:612-423-4194
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-07-07
Last Update Date:2014-07-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNR220414-7163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse