1013080027 NPI number — MRS. LISA DELORIS SLADE FNP-BC

Table of content: MRS. LISA DELORIS SLADE FNP-BC (NPI 1013080027)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1013080027 NPI number — MRS. LISA DELORIS SLADE FNP-BC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
SLADE
Provider First Name:
LISA
Provider Middle Name:
DELORIS
Provider Name Prefix Text:
MRS.
Provider Name Suffix Text:
Provider Credential Text:
FNP-BC
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1013080027
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
01/09/2015
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 1729
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
HATTIESBURG
Provider Business Mailing Address State Name:
MS
Provider Business Mailing Address Postal Code:
39403-1729
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
601-545-3700
Provider Business Mailing Address Fax Number:
601-450-2493

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
605 STADIUM DR
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
HATTIESBURG
Provider Business Practice Location Address State Name:
MS
Provider Business Practice Location Address Postal Code:
39401-4156
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
601-450-0310
Provider Business Practice Location Address Fax Number:
601-450-0321
Provider Enumeration Date:
11/16/2006

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: 363LF0000X , with the licence number:  R772518 , registered in the state of MS ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 08700008 , issued by the state of ( MS ) . This identifiers is of the category "MEDICAID".
  • Identifier: 11838342 . This is a "CAQH ID #" identifier , issued by the state of ( MS ) . This identifiers is of the category "OTHER".
  • Identifier: 1719640P01 . This is a "CIGNA" identifier , issued by the state of ( MS ) . This identifiers is of the category "OTHER".
  • Identifier: 1043492770 . This is a "FIRST CHOICE OF MISSISSIPPI" identifier , issued by the state of ( MS ) . This identifiers is of the category "OTHER".
  • Identifier: 2888996 . This is a "UNITED HEALTH CARE" identifier , issued by the state of ( MS ) . This identifiers is of the category "OTHER".
  • Identifier: 9989130 . This is a "AETNA" identifier , issued by the state of ( MS ) . This identifiers is of the category "OTHER".




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