Provider Demographics
NPI:1619947975
Name:PURCELL, LISA B (NP)
Entity Type:Individual
Prefix:
First Name:LISA
Middle Name:B
Last Name:PURCELL
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:LISA
Other - Middle Name:MICHELLE
Other - Last Name:BRIDWELL
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:300 E MCBEE AVE FL 4
Mailing Address - Street 2:
Mailing Address - City:GREENVILLE
Mailing Address - State:SC
Mailing Address - Zip Code:29601-2842
Mailing Address - Country:US
Mailing Address - Phone:864-522-8603
Mailing Address - Fax:864-797-6198
Practice Address - Street 1:100 OMNI DR STE B
Practice Address - Street 2:
Practice Address - City:SENECA
Practice Address - State:SC
Practice Address - Zip Code:29672-9448
Practice Address - Country:US
Practice Address - Phone:864-886-9250
Practice Address - Fax:864-886-9251
Is Sole Proprietor?:No
Enumeration Date:2006-01-26
Last Update Date:2024-01-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC2064363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCNP1130Medicaid
SCAA09881856Medicare PIN
SCQ48312Medicare UPIN