Provider Demographics
NPI:1114078839
Name:MEJIA, LISA PENTON (APRN)
Entity Type:Individual
Prefix:MS
First Name:LISA
Middle Name:PENTON
Last Name:MEJIA
Suffix:
Gender:F
Credentials:APRN
Other - Prefix:MS
Other - First Name:LISA
Other - Middle Name:PENTON
Other - Last Name:HERRING
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:APRN
Mailing Address - Street 1:5959 S SHERWOOD FOREST BLVD
Mailing Address - Street 2:
Mailing Address - City:BATON ROUGE
Mailing Address - State:LA
Mailing Address - Zip Code:70816-6038
Mailing Address - Country:US
Mailing Address - Phone:225-526-0018
Mailing Address - Fax:225-765-9196
Practice Address - Street 1:433 PLAZA ST STE 38
Practice Address - Street 2:
Practice Address - City:BOGALUSA
Practice Address - State:LA
Practice Address - Zip Code:70427-3729
Practice Address - Country:US
Practice Address - Phone:987-730-2284
Practice Address - Fax:985-730-2305
Is Sole Proprietor?:No
Enumeration Date:2007-01-16
Last Update Date:2018-02-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LAAP04640363LA2100X, 363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health
No363LA2100XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAcute Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1457825Medicaid
LA1457825Medicaid