Provider Demographics
NPI:1710210794
Name:LATHEM, LISA (NP)
Entity Type:Individual
Prefix:MRS
First Name:LISA
Middle Name:
Last Name:LATHEM
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 23666
Mailing Address - Street 2:
Mailing Address - City:JACKSON
Mailing Address - State:MS
Mailing Address - Zip Code:39225-3666
Mailing Address - Country:US
Mailing Address - Phone:601-200-4749
Mailing Address - Fax:601-200-5929
Practice Address - Street 1:971 LAKELAND DR
Practice Address - Street 2:SUITE 557
Practice Address - City:JACKSON
Practice Address - State:MS
Practice Address - Zip Code:39216-4643
Practice Address - Country:US
Practice Address - Phone:601-200-4560
Practice Address - Fax:601-326-4632
Is Sole Proprietor?:No
Enumeration Date:2009-09-09
Last Update Date:2015-04-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSR672106363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
MSP01410915OtherRAILROAD MEDICARE
MS05721214Medicaid
MSP01410915OtherRAILROAD MEDICARE