Provider Demographics
NPI:1275307472
Name:SOUTH, LISA LARAINE (NP)
Entity Type:Individual
Prefix:
First Name:LISA
Middle Name:LARAINE
Last Name:SOUTH
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9373 N WALKER RD
Mailing Address - Street 2:
Mailing Address - City:CLEVELAND
Mailing Address - State:TX
Mailing Address - Zip Code:77328-5835
Mailing Address - Country:US
Mailing Address - Phone:832-797-9670
Mailing Address - Fax:
Practice Address - Street 1:180 W ESPLANADE AVE
Practice Address - Street 2:
Practice Address - City:KENNER
Practice Address - State:LA
Practice Address - Zip Code:70065-2467
Practice Address - Country:US
Practice Address - Phone:504-464-8506
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-11-08
Last Update Date:2023-11-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX1134088363LG0600X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LG0600XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGerontology