Healthcare Provider Details

I. General information

NPI: 1194222505
Provider Name (Legal Business Name): LISA NICOLE MORRISON
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/11/2018
Last Update Date: 04/11/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1245 ROSEMONT DR STE 120
FORT MILL SC
29707-7765
US

IV. Provider business mailing address

3024 VENTOSA DR
CHARLOTTE NC
28205-3241
US

V. Phone/Fax

Practice location:
  • Phone: 803-548-8100
  • Fax:
Mailing address:
  • Phone: 803-548-8100
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number21710
License Number StateSC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: