Provider Demographics
NPI:1649719816
Name:STALEY, LISA RENEE (NP)
Entity type:Individual
Prefix:
First Name:LISA
Middle Name:RENEE
Last Name:STALEY
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:LISA
Other - Middle Name:RENEE
Other - Last Name:LEE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:LPN
Mailing Address - Street 1:6435 W JEFFERSON BLVD
Mailing Address - Street 2:
Mailing Address - City:FORT WAYNE
Mailing Address - State:IN
Mailing Address - Zip Code:46804-6203
Mailing Address - Country:US
Mailing Address - Phone:260-344-4035
Mailing Address - Fax:260-969-9272
Practice Address - Street 1:800 W MAIN ST
Practice Address - Street 2:
Practice Address - City:COLDWATER
Practice Address - State:OH
Practice Address - Zip Code:45828-1613
Practice Address - Country:US
Practice Address - Phone:260-344-4035
Practice Address - Fax:260-969-9272
Is Sole Proprietor?:No
Enumeration Date:2017-02-21
Last Update Date:2017-03-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHAPRN.CNP.020584363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily