Healthcare Provider Details

I. General information

NPI: 1063351211
Provider Name (Legal Business Name): LISA ANN CULLISON APRN, PMHNP-BC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/25/2026
Last Update Date: 04/14/2026
Certification Date: 04/14/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

19567 HARBLE RD
LOGAN OH
43138-7538
US

IV. Provider business mailing address

19567 HARBLE RD
LOGAN OH
43138-7538
US

V. Phone/Fax

Practice location:
  • Phone: 386-453-4105
  • Fax:
Mailing address:
  • Phone: 386-453-4105
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License NumberAPRN.CNP.0041844
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: