Provider Demographics
NPI:1053507798
Name:PRIMM, LISA CAROLE (ARNP)
Entity Type:Individual
Prefix:MS
First Name:LISA
Middle Name:CAROLE
Last Name:PRIMM
Suffix:
Gender:F
Credentials:ARNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 3299
Mailing Address - Street 2:
Mailing Address - City:CARSON CITY
Mailing Address - State:NV
Mailing Address - Zip Code:89702-3299
Mailing Address - Country:US
Mailing Address - Phone:775-240-6758
Mailing Address - Fax:888-700-0187
Practice Address - Street 1:828 LANE ALLEN RD STE 219
Practice Address - Street 2:
Practice Address - City:LEXINGTON
Practice Address - State:KY
Practice Address - Zip Code:40504
Practice Address - Country:US
Practice Address - Phone:502-498-4071
Practice Address - Fax:888-423-5216
Is Sole Proprietor?:No
Enumeration Date:2007-09-17
Last Update Date:2018-07-24
Deactivation Date:2010-06-18
Deactivation Code:
Reactivation Date:2010-08-25
Provider Licenses
StateLicense IDTaxonomies
KY5409P363L00000X
KY3005409364SF0001X
KY1099062363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No364SF0001XPhysician Assistants & Advanced Practice Nursing ProvidersClinical Nurse SpecialistFamily Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN7100050650Medicaid
KY50029934OtherPASSPORT HEALTH PLAN
IN7100050650Medicaid