Provider Demographics
NPI:1164660635
Name:LISA BYRD HEALTHCARE INC
Entity Type:Organization
Organization Name:LISA BYRD HEALTHCARE INC
Other - Org Name:BOLTON FAMILY CLINIC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:LISA
Authorized Official - Middle Name:
Authorized Official - Last Name:BYRD
Authorized Official - Suffix:
Authorized Official - Credentials:CFNP
Authorized Official - Phone:601-866-7723
Mailing Address - Street 1:PO BOX 217
Mailing Address - Street 2:
Mailing Address - City:BOLTON
Mailing Address - State:MS
Mailing Address - Zip Code:39041-0217
Mailing Address - Country:US
Mailing Address - Phone:601-866-7723
Mailing Address - Fax:601-866-7773
Practice Address - Street 1:115 W MADISON ST
Practice Address - Street 2:
Practice Address - City:BOLTON
Practice Address - State:MS
Practice Address - Zip Code:39041-3209
Practice Address - Country:US
Practice Address - Phone:601-866-7723
Practice Address - Fax:601-866-7773
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:MISSISSIPPI NURSE PRACTITIONERS INC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2009-01-22
Last Update Date:2009-01-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSR652075363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGroup - Multi-Specialty