MEDICARE: LISA STREET NP-C

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	363LF0000X	Family Nurse Practitioner	APN0000018460	TN

General Provider Information

NPI Number	:	1528473444
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	LISA STREET NP-C

Provider Business Mailing Address
First Line	:	703 NEW YORK ST
Second Line	:
City	:	MEMPHIS
State	:	TN
Zip	:	38104-5537
Country	:	US
Telephone Number	:	901-237-7599
Fax Number	:

Provider Business Practice Location Address
First Line	:	6005 PARK AVE STE 400
Second Line	:
City	:	MEMPHIS
State	:	TN
Zip	:	38119-5214
Country	:	US
Telephone Number	:	901-767-7324
Fax Number	:

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

Provider Enumeration Date	:	06/30/2014
Last Update Date	:	06/30/2014

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