Healthcare Provider Details

I. General information

NPI: 1760356745
Provider Name (Legal Business Name): LYSANDRA OLIVER FNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/02/2025
Last Update Date: 02/19/2026
Certification Date: 02/19/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

302 MOUNT TABOR RD
RED SPRINGS NC
28377-6415
US

IV. Provider business mailing address

60 COMMERCE PLAZA CIR
PEMBROKE NC
28372-7386
US

V. Phone/Fax

Practice location:
  • Phone: 910-227-2850
  • Fax: 910-227-2847
Mailing address:
  • Phone: 910-521-2900
  • Fax: 910-775-9165

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number5023991
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: