1003055955 NPI number — MS. LISSA WEST FNP

Table of content: MS. LISSA WEST FNP (NPI 1003055955)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1003055955 NPI number — MS. LISSA WEST FNP

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
WEST
Provider First Name:
LISSA
Provider Middle Name:
Provider Name Prefix Text:
MS.
Provider Name Suffix Text:
Provider Credential Text:
FNP
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
WEST
Provider Other First Name:
ELIZABETH
Provider Other Middle Name:
ALICE
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
R.N.
Provider Other Last Name Type Code:
5

NPI Number Information

NPI Number:
1003055955
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
09/21/2018
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
3606 MACLAY BLVD STE 102
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
TALLAHASSEE
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
32312
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
805-877-1162
Provider Business Mailing Address Fax Number:
850-671-5009

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
3606 MACLAY BLVD STE 102
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
TALLAHASSEE
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
32312
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
805-877-1162
Provider Business Practice Location Address Fax Number:
850-671-5009
Provider Enumeration Date:
02/17/2009

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 163WP0200X , with the licence number:  115113 R.N. , registered in the state of TN ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 364SP0200X , with the licence number: 7609 A.P.N. , registered in the state of TN ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 163WP0200X , with the licence number: 07609 , registered in the state of TN ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 5440116 , issued by the state of ( TN ) . This identifiers is of the category "MEDICAID".