Provider Demographics
NPI:1003055955
Name:WEST, LISSA (FNP)
Entity type:Individual
Prefix:MS
First Name:LISSA
Middle Name:
Last Name:WEST
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:
Other - First Name:ELIZABETH
Other - Middle Name:ALICE
Other - Last Name:WEST
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:RN
Mailing Address - Street 1:3606 MACLAY BLVD STE 102
Mailing Address - Street 2:
Mailing Address - City:TALLAHASSEE
Mailing Address - State:FL
Mailing Address - Zip Code:32312
Mailing Address - Country:US
Mailing Address - Phone:805-877-1162
Mailing Address - Fax:850-671-5009
Practice Address - Street 1:3606 MACLAY BLVD STE 102
Practice Address - Street 2:
Practice Address - City:TALLAHASSEE
Practice Address - State:FL
Practice Address - Zip Code:32312
Practice Address - Country:US
Practice Address - Phone:805-877-1162
Practice Address - Fax:850-671-5009
Is Sole Proprietor?:Yes
Enumeration Date:2009-02-17
Last Update Date:2018-09-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN115113 R.N.163WP0200X
TN7609 A.P.N.364SP0200X
TN07609163WP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WP0200XNursing Service ProvidersRegistered NursePediatrics
No364SP0200XPhysician Assistants & Advanced Practice Nursing ProvidersClinical Nurse SpecialistPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN5440116Medicaid