=====================================================
General NPI Number Information
=====================================================
NPI Number | 1003579780
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | LISA DOTSON RN
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/19/2021
-----------------------------------------------------
Last Update Date | 10/19/2021
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1217 US HIGHWARY 62E
-----------------------------------------------------
City | CYNTHIANA
-----------------------------------------------------
State | KY
-----------------------------------------------------
Zip | 41031
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 859-234-2702
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1400 WHETSTONE RD
-----------------------------------------------------
City | CARLISLE
-----------------------------------------------------
State | KY
-----------------------------------------------------
Zip | 40311-9074
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 407-310-8364
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 314000000X
-----------------------------------------------------
Taxonomy Name | Skilled Nursing Facility
-----------------------------------------------------
License Number | 1158022
-----------------------------------------------------
License Number State | KY
-----------------------------------------------------