Individual
LISA OMO-GRIFFITH
Active
Sole proprietor
No
Provider details
NPI number
Gender
F
Credential
N.P.
Contact information
Practice address
5646 COVENTRY LN, FORT WAYNE, IN 46804-7140
(260) 203-5441
Mailing address
6809 COVINGTON CREEK TRL, FORT WAYNE, IN 46804-2871
(260) 437-4173
(260) 918-6855
Taxonomy
Speciality
Code
Description
License number
State
163W00000X
Registered Nurse
28156677
IN
363LF0000X
Family Nurse Practitioner
Primary
71003136
IN
363LF0000X
Family Nurse Practitioner
COA13460
OH
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
000000682872
ANTHEM
IN
05
—
0069880
—
OH
05
—
200999600
—
IN
01
—
P01044179
R.R. MEDICARE
IN
Enumeration date
06/14/2010
Last updated
09/11/2023
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