Provider Demographics
NPI:1508962101
Name:BLESSE, LISA GRAHAM (FNP)
Entity Type:Individual
Prefix:MRS
First Name:LISA
Middle Name:GRAHAM
Last Name:BLESSE
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 1:14 MAPLERIDGE ST
Mailing Address - Street 2:
Mailing Address - City:HATTIESBURG
Mailing Address - State:MS
Mailing Address - Zip Code:39402-8864
Mailing Address - Country:US
Mailing Address - Phone:601-271-8857
Mailing Address - Fax:
Practice Address - Street 1:1101 HIGHWAY 11 S
Practice Address - Street 2:
Practice Address - City:ELLISVILLE
Practice Address - State:MS
Practice Address - Zip Code:39437-4443
Practice Address - Country:US
Practice Address - Phone:601-477-5795
Practice Address - Fax:601-477-5895
Is Sole Proprietor?:No
Enumeration Date:2006-09-15
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSR842124363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS00125048Medicaid
MS00125048Medicaid
MSP50667Medicare UPIN