Provider Demographics
NPI:1821728361
Name:MAX, LYSSA
Entity Type:Individual
Prefix:
First Name:LYSSA
Middle Name:
Last Name:MAX
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 1:211 TANGLEWOOD LN
Mailing Address - Street 2:
Mailing Address - City:HENDERSONVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:37075-1479
Mailing Address - Country:US
Mailing Address - Phone:813-295-0126
Mailing Address - Fax:
Practice Address - Street 1:211 TANGLEWOOD LN
Practice Address - Street 2:
Practice Address - City:HENDERSONVILLE
Practice Address - State:TN
Practice Address - Zip Code:37075-1479
Practice Address - Country:US
Practice Address - Phone:813-295-0126
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-06-16
Last Update Date:2022-06-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNAPN0000031197363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGroup - Single Specialty