Provider Demographics
NPI:1003485517
Name:XAYASONE, LISA
Entity Type:Individual
Prefix:
First Name:LISA
Middle Name:
Last Name:XAYASONE
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 1:10133 SHERRILL BLVD STE 200
Mailing Address - Street 2:
Mailing Address - City:KNOXVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:37932-3347
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1806 MAPLELEAF BLVD
Practice Address - Street 2:
Practice Address - City:OLDSMAR
Practice Address - State:FL
Practice Address - Zip Code:34677-2732
Practice Address - Country:US
Practice Address - Phone:737-244-5391
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-06-18
Last Update Date:2021-06-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL11802225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant