MEDICARE: MRS. LISA DAWN ANTHONY

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	246Z00000X	Other Specialist/Technologist

General Provider Information

NPI Number	:	1265418453
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MRS. LISA DAWN ANTHONY

Provider Business Mailing Address
First Line	:	2301 E FORT MACON RD
Second Line	:
City	:	ATLANTIC BEACH
State	:	NC
Zip	:	28512-5633
Country	:	US
Telephone Number	:	252-241-0670
Fax Number	:	252-240-8447

Provider Business Practice Location Address
First Line	:	2301 E FORT MACON RD
Second Line	:
City	:	ATLANTIC BEACH
State	:	NC
Zip	:	28512-5633
Country	:	US
Telephone Number	:	252-241-0670
Fax Number	:	252-240-8447

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	12/20/2005
Last Update Date	:	07/08/2007

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