Provider Demographics
NPI:1225611080
Name:FELLOWS, LISA
Entity Type:Individual
Prefix:
First Name:LISA
Middle Name:
Last Name:FELLOWS
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 1:10 COLONY CV
Mailing Address - Street 2:
Mailing Address - City:WHITE HALL
Mailing Address - State:AR
Mailing Address - Zip Code:71602-8930
Mailing Address - Country:US
Mailing Address - Phone:870-718-7431
Mailing Address - Fax:
Practice Address - Street 1:10 COLONY CV
Practice Address - Street 2:
Practice Address - City:WHITE HALL
Practice Address - State:AR
Practice Address - Zip Code:71602-8930
Practice Address - Country:US
Practice Address - Phone:870-718-7431
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-04-29
Last Update Date:2021-09-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARAR57333747P1801X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3747P1801XNursing Service Related ProvidersTechnicianPersonal Care Attendant