Provider Demographics
NPI:1669920146
Name:KIRKTON, LISA
Entity type:Individual
Prefix:
First Name:LISA
Middle Name:
Last Name:KIRKTON
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 1:10209 FOREST LAKES DR
Mailing Address - Street 2:
Mailing Address - City:MIDDLEBURY
Mailing Address - State:IN
Mailing Address - Zip Code:46540-9413
Mailing Address - Country:US
Mailing Address - Phone:574-238-2503
Mailing Address - Fax:
Practice Address - Street 1:2600 OAKLAND AVE
Practice Address - Street 2:
Practice Address - City:ELKHART
Practice Address - State:IN
Practice Address - Zip Code:46517-1533
Practice Address - Country:US
Practice Address - Phone:574-533-1234
Practice Address - Fax:574-522-5783
Is Sole Proprietor?:No
Enumeration Date:2016-09-14
Last Update Date:2016-09-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN71006510363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health