Provider Demographics
NPI:1568104560
Name:DODDS, LISA (RN)
Entity Type:Individual
Prefix:
First Name:LISA
Middle Name:
Last Name:DODDS
Suffix:
Gender:F
Credentials:RN
Other - Prefix:
Other - First Name:LISA
Other - Middle Name:
Other - Last Name:GLASS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:RN
Mailing Address - Street 1:2135 STARDUSTER LN
Mailing Address - Street 2:
Mailing Address - City:LITTLE RIVER
Mailing Address - State:SC
Mailing Address - Zip Code:29566-9729
Mailing Address - Country:US
Mailing Address - Phone:910-269-9768
Mailing Address - Fax:
Practice Address - Street 1:4437 MAIN ST
Practice Address - Street 2:
Practice Address - City:SHALLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28470-4451
Practice Address - Country:US
Practice Address - Phone:910-754-4449
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-04-11
Last Update Date:2022-04-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC243002163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse