Provider Demographics
NPI:1841417649
Name:MILLS, LISA SIMS (MD)
Entity Type:Individual
Prefix:
First Name:LISA
Middle Name:SIMS
Last Name:MILLS
Suffix:
Gender:F
Credentials:MD
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 60447
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28260-0447
Mailing Address - Country:US
Mailing Address - Phone:704-384-7508
Mailing Address - Fax:704-384-8666
Practice Address - Street 1:2630 E 7TH ST
Practice Address - Street 2:
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28204-4318
Practice Address - Country:US
Practice Address - Phone:704-384-7508
Practice Address - Fax:704-384-8666
Is Sole Proprietor?:No
Enumeration Date:2007-04-20
Last Update Date:2023-06-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC200900234208000000X, 208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCNC1049Medicaid
NC5912001Medicaid