Healthcare Provider Details

I. General information

NPI: 1306248182
Provider Name (Legal Business Name): LISA DAWN BOOTH F.N.P.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/23/2014
Last Update Date: 03/28/2024
Certification Date: 01/23/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

145 INNOVATION DR
JACKSON TN
38305-3019
US

IV. Provider business mailing address

PO BOX 400
JACKSON TN
38302-0400
US

V. Phone/Fax

Practice location:
  • Phone: 731-422-0213
  • Fax: 731-422-0475
Mailing address:
  • Phone: 731-422-0213
  • Fax: 731-660-8369

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number19109
License Number StateTN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: