Provider Demographics
NPI:1013636729
Name:HARRELSON, LISA MARIE (DNP)
Entity Type:Individual
Prefix:
First Name:LISA
Middle Name:MARIE
Last Name:HARRELSON
Suffix:
Gender:F
Credentials:DNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4453 CASTOR AVE STE B
Mailing Address - Street 2:
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19124-3846
Mailing Address - Country:US
Mailing Address - Phone:215-744-2266
Mailing Address - Fax:
Practice Address - Street 1:4453 CASTOR AVE STE B
Practice Address - Street 2:
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19124-3846
Practice Address - Country:US
Practice Address - Phone:215-744-2266
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-08-25
Last Update Date:2022-08-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PASP026175363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily