Provider Demographics
NPI:1033434519
Name:SUDDRETH, LISA MARIE (MSN, NP-C, PMHNP-BC)
Entity Type:Individual
Prefix:MRS
First Name:LISA
Middle Name:MARIE
Last Name:SUDDRETH
Suffix:
Gender:F
Credentials:MSN, NP-C, PMHNP-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4089 BORDEAUX DR.
Mailing Address - Street 2:
Mailing Address - City:DENVER
Mailing Address - State:NC
Mailing Address - Zip Code:28037
Mailing Address - Country:US
Mailing Address - Phone:980-434-8236
Mailing Address - Fax:704-917-7615
Practice Address - Street 1:830 SUMMIT CROSSING PL
Practice Address - Street 2:
Practice Address - City:GASTONIA
Practice Address - State:NC
Practice Address - Zip Code:28054-2192
Practice Address - Country:US
Practice Address - Phone:704-917-7610
Practice Address - Fax:704-917-7615
Is Sole Proprietor?:No
Enumeration Date:2010-03-29
Last Update Date:2018-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC5004669363LF0000X, 363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC2594812Medicare PIN