Provider Demographics
NPI:1386013480
Name:LISENBY, STEPHANIE NICOLE (FNP)
Entity Type:Individual
Prefix:
First Name:STEPHANIE
Middle Name:NICOLE
Last Name:LISENBY
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 19305
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28219-9305
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:10210 COULOAK DR
Practice Address - Street 2:STE E
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28216-7679
Practice Address - Country:US
Practice Address - Phone:704-801-2000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-09-18
Last Update Date:2023-12-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC5007975363L00000X, 363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC1386013480Medicaid
SCQNP328Medicaid
SCQNP328Medicaid
NCNCQ457DMedicare PIN
NCNCQ457EMedicare PIN
NCNCQ457AMedicare PIN
NCNCQ457BMedicare PIN