Provider Demographics
NPI:1174829634
Name:CARTER, LISA YVONNE (APN)
Entity Type:Individual
Prefix:
First Name:LISA
Middle Name:YVONNE
Last Name:CARTER
Suffix:
Gender:F
Credentials:APN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:112 PEARSON
Mailing Address - Street 2:
Mailing Address - City:BENTON
Mailing Address - State:AR
Mailing Address - Zip Code:72015-4436
Mailing Address - Country:US
Mailing Address - Phone:501-326-6720
Mailing Address - Fax:501-778-0450
Practice Address - Street 1:112 PEARSON
Practice Address - Street 2:
Practice Address - City:BENTON
Practice Address - State:AR
Practice Address - Zip Code:72015-4436
Practice Address - Country:US
Practice Address - Phone:501-326-6720
Practice Address - Fax:501-778-0450
Is Sole Proprietor?:No
Enumeration Date:2011-02-01
Last Update Date:2016-08-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARR68406171M00000X
ARA003513363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
No171M00000XOther Service ProvidersCase Manager/Care Coordinator
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR185386795Medicaid