Provider Demographics
NPI:1891847869
Name:MALLARD, LISA (ARNP, CNM)
Entity Type:Individual
Prefix:
First Name:LISA
Middle Name:
Last Name:MALLARD
Suffix:
Gender:F
Credentials:ARNP, CNM
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 936
Mailing Address - Street 2:
Mailing Address - City:LONDON
Mailing Address - State:KY
Mailing Address - Zip Code:40743-0936
Mailing Address - Country:US
Mailing Address - Phone:606-330-7835
Mailing Address - Fax:
Practice Address - Street 1:170 N EAGLE CREEK DR STE 104
Practice Address - Street 2:
Practice Address - City:LEXINGTON
Practice Address - State:KY
Practice Address - Zip Code:40509-9087
Practice Address - Country:US
Practice Address - Phone:859-967-5848
Practice Address - Fax:859-967-5473
Is Sole Proprietor?:No
Enumeration Date:2007-01-18
Last Update Date:2022-12-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLARNP 2157582367A00000X
KY3009349367A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367A00000XPhysician Assistants & Advanced Practice Nursing ProvidersAdvanced Practice Midwife
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY7100503870Medicaid