Provider Demographics
NPI:1508968256
Name:FAIRCLOTH, LISA PATTERSON (FNP-C)
Entity Type:Individual
Prefix:
First Name:LISA
Middle Name:PATTERSON
Last Name:FAIRCLOTH
Suffix:
Gender:F
Credentials:FNP-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:906 N 5TH ST STE D
Mailing Address - Street 2:
Mailing Address - City:CORDELE
Mailing Address - State:GA
Mailing Address - Zip Code:31015-3224
Mailing Address - Country:US
Mailing Address - Phone:229-271-4630
Mailing Address - Fax:229-271-4631
Practice Address - Street 1:906 N 5TH ST STE D
Practice Address - Street 2:
Practice Address - City:CORDELE
Practice Address - State:GA
Practice Address - Zip Code:31015-3224
Practice Address - Country:US
Practice Address - Phone:229-271-4630
Practice Address - Fax:229-271-4631
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-02
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA154242363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
50BBJVTMedicare ID - Type Unspecified
Q55316Medicare UPIN