Provider Demographics
NPI:1689979510
Name:MATHER, LISA L (LPN, IBCLC, RLC)
Entity Type:Individual
Prefix:
First Name:LISA
Middle Name:L
Last Name:MATHER
Suffix:
Gender:F
Credentials:LPN, IBCLC, RLC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12525 CEDAR FALL DR
Mailing Address - Street 2:
Mailing Address - City:HUNTERSVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:28078
Mailing Address - Country:US
Mailing Address - Phone:980-213-5867
Mailing Address - Fax:
Practice Address - Street 1:12515 CEDAR FALL DRIVE
Practice Address - Street 2:
Practice Address - City:HUNTERSVILLE
Practice Address - State:NC
Practice Address - Zip Code:28078
Practice Address - Country:US
Practice Address - Phone:980-213-5867
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-01-25
Last Update Date:2011-01-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC049048164W00000X
NC101-117460174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
No164W00000XNursing Service ProvidersLicensed Practical Nurse