Provider Demographics
NPI:1407100787
Name:RICHMOND, NISHA LAVORIAN (FNP-C, PMHNP-BC)
Entity Type:Individual
Prefix:
First Name:NISHA
Middle Name:LAVORIAN
Last Name:RICHMOND
Suffix:
Gender:F
Credentials:FNP-C, PMHNP-BC
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 55826
Mailing Address - Street 2:
Mailing Address - City:JACKSON
Mailing Address - State:MS
Mailing Address - Zip Code:39296-5826
Mailing Address - Country:US
Mailing Address - Phone:704-726-4241
Mailing Address - Fax:
Practice Address - Street 1:1621 W PEACE ST
Practice Address - Street 2:
Practice Address - City:CANTON
Practice Address - State:MS
Practice Address - Zip Code:39046-9041
Practice Address - Country:US
Practice Address - Phone:601-391-2716
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-11-07
Last Update Date:2022-01-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXAP122759363LF0000X, 363LP0808X
MS902315363LP0808X, 363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS05252761Medicaid