Provider Demographics
NPI:1013080027
Name:SLADE, LISA DELORIS (FNP-BC)
Entity Type:Individual
Prefix:MRS
First Name:LISA
Middle Name:DELORIS
Last Name:SLADE
Suffix:
Gender:F
Credentials:FNP-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
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Other - Credentials:
Mailing Address - Street 1:PO BOX 1729
Mailing Address - Street 2:
Mailing Address - City:HATTIESBURG
Mailing Address - State:MS
Mailing Address - Zip Code:39403-1729
Mailing Address - Country:US
Mailing Address - Phone:601-545-3700
Mailing Address - Fax:601-450-2493
Practice Address - Street 1:605 STADIUM DR
Practice Address - Street 2:
Practice Address - City:HATTIESBURG
Practice Address - State:MS
Practice Address - Zip Code:39401-4156
Practice Address - Country:US
Practice Address - Phone:601-450-0310
Practice Address - Fax:601-450-0321
Is Sole Proprietor?:No
Enumeration Date:2006-11-16
Last Update Date:2015-01-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSR772518363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS08700008Medicaid
MS11838342OtherCAQH ID #
MS1719640P01OtherCIGNA
MS1043492770OtherFIRST CHOICE OF MISSISSIPPI
MS2888996OtherUNITED HEALTH CARE
MS9989130OtherAETNA
MS1719640P01OtherCIGNA