Provider Demographics
NPI:1922628379
Name:LAND, LISA MICHELLE (NP)
Entity Type:Individual
Prefix:
First Name:LISA
Middle Name:MICHELLE
Last Name:LAND
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 1:10628 PARK RD
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28210-8407
Mailing Address - Country:US
Mailing Address - Phone:702-743-8647
Mailing Address - Fax:
Practice Address - Street 1:10628 PARK RD
Practice Address - Street 2:
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28210-8407
Practice Address - Country:US
Practice Address - Phone:702-743-8647
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-04-24
Last Update Date:2022-05-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC263119163W00000X
NC2021096899363LA2100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2100XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAcute Care
No163W00000XNursing Service ProvidersRegistered Nurse