Provider Demographics
NPI:1487631461
Name:MORGAN, LISA D (FNP-BC)
Entity Type:Individual
Prefix:
First Name:LISA
Middle Name:D
Last Name:MORGAN
Suffix:
Gender:F
Credentials:FNP-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:415 S 28TH AVE
Mailing Address - Street 2:
Mailing Address - City:HATTIESBURG
Mailing Address - State:MS
Mailing Address - Zip Code:39401-7246
Mailing Address - Country:US
Mailing Address - Phone:601-928-4412
Mailing Address - Fax:601-579-5240
Practice Address - Street 1:805 HALL ST
Practice Address - Street 2:
Practice Address - City:WIGGINS
Practice Address - State:MS
Practice Address - Zip Code:39577-2110
Practice Address - Country:US
Practice Address - Phone:601-928-4412
Practice Address - Fax:601-928-4792
Is Sole Proprietor?:No
Enumeration Date:2005-12-29
Last Update Date:2016-08-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MTR763321363LF0000X
MSR763321363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS05788218Medicaid
MS11740143OtherCAQH ID NUMBER
MS05788218Medicaid
MS500001968Medicare PIN