Provider Demographics
NPI:1831298397
Name:HASTON-FULLER, LISA RENEE (DO)
Entity Type:Individual
Prefix:DR
First Name:LISA
Middle Name:RENEE
Last Name:HASTON-FULLER
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:PO BOX 401259
Mailing Address - Street 2:
Mailing Address - City:REDFORD
Mailing Address - State:MI
Mailing Address - Zip Code:48240-9259
Mailing Address - Country:US
Mailing Address - Phone:248-557-4999
Mailing Address - Fax:
Practice Address - Street 1:9315 TELEGRAPH RD
Practice Address - Street 2:
Practice Address - City:REDFORD
Practice Address - State:MI
Practice Address - Zip Code:48239
Practice Address - Country:US
Practice Address - Phone:313-450-4500
Practice Address - Fax:313-450-4514
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-21
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI51010111982084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
BH3040968OtherDEA