Provider Demographics
NPI:1356708069
Name:TABAKIAN, LISA CAROL (APRN)
Entity type:Individual
Prefix:
First Name:LISA
Middle Name:CAROL
Last Name:TABAKIAN
Suffix:
Gender:F
Credentials:APRN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:631 JOHNNIE DODDS BLVD
Mailing Address - Street 2:
Mailing Address - City:MOUNT PLEASANT
Mailing Address - State:SC
Mailing Address - Zip Code:29464-3030
Mailing Address - Country:US
Mailing Address - Phone:843-881-0815
Mailing Address - Fax:
Practice Address - Street 1:631 JOHNNIE DODDS BLVD
Practice Address - Street 2:
Practice Address - City:MOUNT PLEASANT
Practice Address - State:SC
Practice Address - Zip Code:29464-3030
Practice Address - Country:US
Practice Address - Phone:843-881-0815
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-01-26
Last Update Date:2023-05-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC19940363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCNP4032Medicaid