Provider Demographics
NPI:1053146225
Name:ROSSBACH, LISA MICHELLE
Entity type:Individual
Prefix:
First Name:LISA
Middle Name:MICHELLE
Last Name:ROSSBACH
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 1:1526 DEVONSHIRE DR
Mailing Address - Street 2:
Mailing Address - City:TROY
Mailing Address - State:MI
Mailing Address - Zip Code:48098-4375
Mailing Address - Country:US
Mailing Address - Phone:248-854-1554
Mailing Address - Fax:
Practice Address - Street 1:11400 4TH ST N APT 604
Practice Address - Street 2:
Practice Address - City:SAINT PETERSBURG
Practice Address - State:FL
Practice Address - Zip Code:33716-2928
Practice Address - Country:US
Practice Address - Phone:248-854-1554
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-09-05
Last Update Date:2024-12-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLRN9287905363LS0200X
MI4704264456363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No363LS0200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerSchool