1912094830 NPI number — DR. LISA E FLETCHER D.M.D

Table of content: DR. LISA E FLETCHER D.M.D (NPI 1912094830)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1912094830 NPI number — DR. LISA E FLETCHER D.M.D

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
FLETCHER
Provider First Name:
LISA
Provider Middle Name:
E
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
D.M.D
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:
1912094830
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
11/18/2022
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
614 BERRY RD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
BULLS GAP
Provider Business Mailing Address State Name:
TN
Provider Business Mailing Address Postal Code:
37711-3821
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
850-218-6789
Provider Business Mailing Address Fax Number:
850-609-6796

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1047 S. HWY 92
Provider Second Line Business Practice Location Address:
SUITE A
Provider Business Practice Location Address City Name:
DANDRIDGE
Provider Business Practice Location Address State Name:
TN
Provider Business Practice Location Address Postal Code:
37725
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
865-397-2956
Provider Business Practice Location Address Fax Number:
865-299-7988
Provider Enumeration Date:
10/10/2006

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: 122300000X , with the licence number:  11049 , registered in the state of FL ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 1223G0001X , with the licence number: 11709 , 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: 11049 . This is a "LICENSE NUMBER" identifier , issued by the state of ( FL ) . This identifiers is of the category "OTHER".
  • Identifier: 67946 . This is a "BLUE CROSS BLUE SHIELD FL" identifier , issued by the state of ( FL ) . This identifiers is of the category "OTHER".
  • Identifier: 529529 . This is a "UNITED CONCORDIA INS CO" identifier , issued by the state of ( FL ) . This identifiers is of the category "OTHER".




Copyright © 2007-2025 www.npivalidator.com