Provider Demographics
NPI:1235862251
Name:BATES, LISA (PMHNP)
Entity Type:Individual
Prefix:
First Name:LISA
Middle Name:
Last Name:BATES
Suffix:
Gender:F
Credentials:PMHNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:713 S MARSHALL ST
Mailing Address - Street 2:
Mailing Address - City:WINSTON SALEM
Mailing Address - State:NC
Mailing Address - Zip Code:27101-5808
Mailing Address - Country:US
Mailing Address - Phone:336-722-7266
Mailing Address - Fax:336-201-0538
Practice Address - Street 1:1901 ADAMS FARM PKWY
Practice Address - Street 2:
Practice Address - City:GREENSBORO
Practice Address - State:NC
Practice Address - Zip Code:27407-6338
Practice Address - Country:US
Practice Address - Phone:336-722-7266
Practice Address - Fax:336-201-0538
Is Sole Proprietor?:No
Enumeration Date:2022-07-07
Last Update Date:2023-03-22
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
VA0024184570363LP0808X
NC5016478363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health