Provider Demographics
NPI:1295431781
Name:PEARSON, LISA C
Entity type:Individual
Prefix:
First Name:LISA
Middle Name:C
Last Name:PEARSON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2558 LANDIS RD
Mailing Address - Street 2:
Mailing Address - City:WINNSBORO
Mailing Address - State:SC
Mailing Address - Zip Code:29180-8414
Mailing Address - Country:US
Mailing Address - Phone:803-738-5514
Mailing Address - Fax:
Practice Address - Street 1:2558 LANDIS RD
Practice Address - Street 2:
Practice Address - City:WINNSBORO
Practice Address - State:SC
Practice Address - Zip Code:29180-8414
Practice Address - Country:US
Practice Address - Phone:803-738-5514
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-02-06
Last Update Date:2023-02-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC004059792172A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172A00000XOther Service ProvidersDriver