Provider Demographics
NPI:1750019725
Name:MIMS, LISA L
Entity type:Individual
Prefix:
First Name:LISA
Middle Name:L
Last Name:MIMS
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 1:504 BURTON ST
Mailing Address - Street 2:
Mailing Address - City:FUQUAY VARINA
Mailing Address - State:NC
Mailing Address - Zip Code:27526-1608
Mailing Address - Country:US
Mailing Address - Phone:919-753-8042
Mailing Address - Fax:919-762-7621
Practice Address - Street 1:504 BURTON ST
Practice Address - Street 2:
Practice Address - City:FUQUAY VARINA
Practice Address - State:NC
Practice Address - Zip Code:27526-1608
Practice Address - Country:US
Practice Address - Phone:919-753-8042
Practice Address - Fax:919-762-7621
Is Sole Proprietor?:Yes
Enumeration Date:2022-08-09
Last Update Date:2022-08-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes311Z00000XNursing & Custodial Care FacilitiesCustodial Care Facility
No311ZA0620XNursing & Custodial Care FacilitiesCustodial Care FacilityAdult Care Home