Provider Demographics
NPI:1831548486
Name:MCKERN, LISA
Entity type:Individual
Prefix:
First Name:LISA
Middle Name:
Last Name:MCKERN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:357 FOGGY LN
Mailing Address - Street 2:
Mailing Address - City:PORT ORANGE
Mailing Address - State:FL
Mailing Address - Zip Code:32129-7812
Mailing Address - Country:US
Mailing Address - Phone:518-331-3733
Mailing Address - Fax:
Practice Address - Street 1:357 FOGGY LN
Practice Address - Street 2:
Practice Address - City:PORT ORANGE
Practice Address - State:FL
Practice Address - Zip Code:32129-7812
Practice Address - Country:US
Practice Address - Phone:386-453-1430
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-06-05
Last Update Date:2016-06-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL372500000X, 372600000X, 376J00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes376J00000XNursing Service Related ProvidersHomemaker
No372500000XNursing Service Related ProvidersChore Provider
No372600000XNursing Service Related ProvidersAdult Companion