Provider Demographics
NPI:1407845829
Name:BYRD, LISA (CFNP)
Entity Type:Individual
Prefix:MRS
First Name:LISA
Middle Name:
Last Name:BYRD
Suffix:
Gender:F
Credentials:CFNP
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 211699
Mailing Address - Street 2:
Mailing Address - City:EAGAN
Mailing Address - State:MN
Mailing Address - Zip Code:55121-3699
Mailing Address - Country:US
Mailing Address - Phone:866-849-0692
Mailing Address - Fax:888-973-8821
Practice Address - Street 1:880 SW 145TH AVE STE 202
Practice Address - Street 2:
Practice Address - City:PEMBROKE PINES
Practice Address - State:FL
Practice Address - Zip Code:33027-6171
Practice Address - Country:US
Practice Address - Phone:866-849-0692
Practice Address - Fax:888-973-8821
Is Sole Proprietor?:Yes
Enumeration Date:2005-10-18
Last Update Date:2024-04-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZAP11697207Q00000X
IL209.024394207Q00000X
TX1059111207Q00000X
OKM0137542207Q00000X
OH0030800207Q00000X
WAAP60485691207Q00000X
OR201508268NPPP207Q00000X
LAAP06038207Q00000X
FLAPRN9467482363LF0000X, 363L00000X
AL3-001421363LF0000X
TN34910363LF0000X
HIAPRN-4525363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamilyGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS00117435Medicaid
MS500000173Medicare PIN
MS00117435Medicaid