Healthcare Provider Details

I. General information

NPI: 1053507798
Provider Name (Legal Business Name): LISA CAROLE PRIMM ARNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/17/2007
Last Update Date: 07/24/2018
Certification Date:
Deactivation Date: 06/18/2010
Reactivation Date: 08/25/2010

III. Provider practice location address

828 LANE ALLEN RD STE 219
LEXINGTON KY
40504
US

IV. Provider business mailing address

PO BOX 3299
CARSON CITY NV
89702-3299
US

V. Phone/Fax

Practice location:
  • Phone: 502-498-4071
  • Fax: 888-423-5216
Mailing address:
  • Phone: 775-240-6758
  • Fax: 888-700-0187

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number5409P
License Number StateKY
# 2
Primary TaxonomyN
Taxonomy Code364SF0001X
TaxonomyFamily Health Clinical Nurse Specialist
License Number3005409
License Number StateKY
# 3
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number1099062
License Number StateKY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: