Provider Demographics
NPI:1639586704
Name:LAFATA, LISA
Entity Type:Individual
Prefix:
First Name:LISA
Middle Name:
Last Name:LAFATA
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1011 ROCK QUARRY RD
Mailing Address - Street 2:
Mailing Address - City:RALEIGH
Mailing Address - State:NC
Mailing Address - Zip Code:27610-3825
Mailing Address - Country:US
Mailing Address - Phone:919-658-5900
Mailing Address - Fax:910-267-8981
Practice Address - Street 1:325 NC HIGHWAY 55 W
Practice Address - Street 2:
Practice Address - City:MOUNT OLIVE
Practice Address - State:NC
Practice Address - Zip Code:28365-8527
Practice Address - Country:US
Practice Address - Phone:919-658-5900
Practice Address - Fax:910-267-8981
Is Sole Proprietor?:No
Enumeration Date:2014-07-21
Last Update Date:2016-12-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC5007011363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily