Provider Demographics
NPI:1649222779
Name:COMETTO, LISA
Entity Type:Individual
Prefix:
First Name:LISA
Middle Name:
Last Name:COMETTO
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:LISA
Other - Middle Name:
Other - Last Name:STANFIELD
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:FNP
Mailing Address - Street 1:PO BOX 485
Mailing Address - Street 2:
Mailing Address - City:COLUMBIA
Mailing Address - State:SC
Mailing Address - Zip Code:29202-0485
Mailing Address - Country:US
Mailing Address - Phone:803-898-8405
Mailing Address - Fax:803-898-8526
Practice Address - Street 1:220 FAISON DR
Practice Address - Street 2:
Practice Address - City:COLUMBIA
Practice Address - State:SC
Practice Address - Zip Code:29203-3210
Practice Address - Country:US
Practice Address - Phone:803-898-8405
Practice Address - Fax:803-898-8526
Is Sole Proprietor?:No
Enumeration Date:2006-05-17
Last Update Date:2009-02-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC67968363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCNP0808Medicaid
SCAA05073353Medicare PIN
SCQ18744Medicare UPIN