Provider Demographics
NPI:1952648123
Name:DAMERON, LISA (FNP)
Entity Type:Individual
Prefix:
First Name:LISA
Middle Name:
Last Name:DAMERON
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5261 CARROLLTON PIKE
Mailing Address - Street 2:SUITE B
Mailing Address - City:WOODLAWN
Mailing Address - State:VA
Mailing Address - Zip Code:24381-3030
Mailing Address - Country:US
Mailing Address - Phone:276-238-8876
Mailing Address - Fax:276-238-8886
Practice Address - Street 1:5261 CARROLLTON PIKE
Practice Address - Street 2:SUITE B
Practice Address - City:WOODLAWN
Practice Address - State:VA
Practice Address - Zip Code:24381-3030
Practice Address - Country:US
Practice Address - Phone:276-238-8876
Practice Address - Fax:276-238-8886
Is Sole Proprietor?:No
Enumeration Date:2013-01-08
Last Update Date:2014-08-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0001217082163W00000X
VA0024170321363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No163W00000XNursing Service ProvidersRegistered Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
261083931OtherTAX ID
VAVV8951AOtherPTAN
DN2980OtherGROUP PTAN
VA1952648123Medicaid