Healthcare Provider Details

I. General information

NPI: 1164672473
Provider Name (Legal Business Name): LISA NELSON
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: LISA SAMPSON MS

II. Dates (important events)

Enumeration Date: 09/23/2008
Last Update Date: 09/23/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

890 RINEYVILLE RD
ELIZABETHTOWN KY
42701-8927
US

IV. Provider business mailing address

890 RINEYVILLE RD
ELIZABETHTOWN KY
42701-8927
US

V. Phone/Fax

Practice location:
  • Phone: 270-234-0577
  • Fax: 270-234-8367
Mailing address:
  • Phone: 270-234-0577
  • Fax: 270-234-8367

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number123
License Number StateKY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: