Provider Demographics
NPI:1033491691
Name:DORROUGH, LISE (LVN)
Entity Type:Individual
Prefix:
First Name:LISE
Middle Name:
Last Name:DORROUGH
Suffix:
Gender:F
Credentials:LVN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3249 CATHEDRAL DR
Mailing Address - Street 2:
Mailing Address - City:GRAND PRAIRIE
Mailing Address - State:TX
Mailing Address - Zip Code:75052-6492
Mailing Address - Country:US
Mailing Address - Phone:214-793-8937
Mailing Address - Fax:972-262-8803
Practice Address - Street 1:3249 CATHEDRAL DR
Practice Address - Street 2:
Practice Address - City:GRAND PRAIRIE
Practice Address - State:TX
Practice Address - Zip Code:75052-6492
Practice Address - Country:US
Practice Address - Phone:214-793-8937
Practice Address - Fax:972-262-8803
Is Sole Proprietor?:Yes
Enumeration Date:2011-09-09
Last Update Date:2011-09-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX136152164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse