Provider Demographics
NPI:1649460544
Name:PROFFITT, LISA KAYE (APRN)
Entity type:Individual
Prefix:MS
First Name:LISA
Middle Name:KAYE
Last Name:PROFFITT
Suffix:
Gender:F
Credentials:APRN
Other - Prefix:
Other - First Name:LISA
Other - Middle Name:KAYE
Other - Last Name:GRIMES
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:APRN
Mailing Address - Street 1:201 PARK ST
Mailing Address - Street 2:
Mailing Address - City:BOWLING GREEN
Mailing Address - State:KY
Mailing Address - Zip Code:42101-1742
Mailing Address - Country:US
Mailing Address - Phone:270-781-5111
Mailing Address - Fax:
Practice Address - Street 1:405 S L ROGERS WELLS BLVD
Practice Address - Street 2:
Practice Address - City:GLASGOW
Practice Address - State:KY
Practice Address - Zip Code:42141-1725
Practice Address - Country:US
Practice Address - Phone:270-479-0260
Practice Address - Fax:270-361-5001
Is Sole Proprietor?:No
Enumeration Date:2007-07-26
Last Update Date:2025-01-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY3005252363LF0000X, 363L00000X
KY5252P363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY7100020460Medicaid