Provider Demographics
NPI:1073582615
Name:PICKETT, LISA R (DNP)
Entity Type:Individual
Prefix:MS
First Name:LISA
Middle Name:R
Last Name:PICKETT
Suffix:
Gender:F
Credentials:DNP
Other - Prefix:MS
Other - First Name:LISA
Other - Middle Name:
Other - Last Name:TITTLE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:DNP
Mailing Address - Street 1:758 S. WILLOW AVE.,
Mailing Address - Street 2:
Mailing Address - City:COOKEVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:38501-3840
Mailing Address - Country:US
Mailing Address - Phone:931-526-6173
Mailing Address - Fax:931-526-6173
Practice Address - Street 1:758 S. WILLOW AVE.,
Practice Address - Street 2:
Practice Address - City:COOKEVILLE
Practice Address - State:TN
Practice Address - Zip Code:38501-3840
Practice Address - Country:US
Practice Address - Phone:931-526-6173
Practice Address - Fax:931-526-6173
Is Sole Proprietor?:No
Enumeration Date:2006-03-16
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN8414363LF0000X
TNAPN8418363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
TNQ004696Medicaid
TNAPN8418OtherSTATE LICENSE NUMBER
TN4123798OtherBCBST
TN3207OtherTN BOARD OF NURSING
TN3207OtherTN BOARD OF NURSING