Provider Demographics
NPI:1225447923
Name:TERRELL, LISA
Entity Type:Individual
Prefix:
First Name:LISA
Middle Name:
Last Name:TERRELL
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:902 SGT. JOHN PITTMAN DRIVE
Mailing Address - Street 2:
Mailing Address - City:GREENWOOD
Mailing Address - State:MS
Mailing Address - Zip Code:38930-2800
Mailing Address - Country:US
Mailing Address - Phone:662-207-5657
Mailing Address - Fax:
Practice Address - Street 1:902 SGT. JOHN PITTMAN DRIVE
Practice Address - Street 2:
Practice Address - City:GREENWOOD
Practice Address - State:MS
Practice Address - Zip Code:38930-2800
Practice Address - Country:US
Practice Address - Phone:662-207-5657
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-08-06
Last Update Date:2015-12-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSR850223363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner