Provider Demographics
NPI:1023105616
Name:DUCOMMUN, LISA M (CNP)
Entity type:Individual
Prefix:
First Name:LISA
Middle Name:M
Last Name:DUCOMMUN
Suffix:
Gender:F
Credentials:CNP
Other - Prefix:
Other - First Name:LISA
Other - Middle Name:M
Other - Last Name:JOHNSON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:300 SIOUX VALLEY DR
Mailing Address - Street 2:
Mailing Address - City:CHEROKEE
Mailing Address - State:IA
Mailing Address - Zip Code:51012-1205
Mailing Address - Country:US
Mailing Address - Phone:712-225-6265
Mailing Address - Fax:712-225-6800
Practice Address - Street 1:300 SIOUX VALLEY DR
Practice Address - Street 2:
Practice Address - City:CHEROKEE
Practice Address - State:IA
Practice Address - Zip Code:51012-1205
Practice Address - Country:US
Practice Address - Phone:712-225-6265
Practice Address - Fax:712-225-6800
Is Sole Proprietor?:No
Enumeration Date:2006-10-06
Last Update Date:2014-10-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IAA-097930364S00000X
MNR176031-0364S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes364S00000XPhysician Assistants & Advanced Practice Nursing ProvidersClinical Nurse Specialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IAA-097930OtherIOWA LICENSE
IA0560631Medicaid
IA27781OtherBLUE CROSS
IAA-097930OtherIOWA LICENSE
SD251754OtherMIDLANDS CHOICE
ND12903Medicaid
SD0125107OtherMEDICA
MN031013001OtherPRIMEWEST
SD370624200OtherDEPT OF LABOR
SD56187B002OtherWPS TRICARE
IAA-097930OtherIOWA LICENSE
SD406751048285OtherPREFERRED ONE
MN522L9AVOtherCC SYSTEMS/ BLUE PLUS
SDHP70924OtherHEALTHPARTNERS
IAI18874Medicare PIN
IA27781OtherBLUE CROSS
MN822915000Medicaid
MN500003622Medicare PIN
SD9241680OtherDAKOTACARE