=====================================================
General NPI Number Information
=====================================================
NPI Number | 1063351211
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | LISA ANN CULLISON APRN, PMHNP-BC
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/25/2026
-----------------------------------------------------
Last Update Date | 03/25/2026
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 19567 HARBLE RD
-----------------------------------------------------
City | LOGAN
-----------------------------------------------------
State | OH
-----------------------------------------------------
Zip | 43138-7538
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 386-453-4105
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 19567 HARBLE RD
-----------------------------------------------------
City | LOGAN
-----------------------------------------------------
State | OH
-----------------------------------------------------
Zip | 43138-7538
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 386-453-4105
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 163WA0400X
-----------------------------------------------------
Taxonomy Name | Addiction (Substance Use Disorder) Registered Nurse
-----------------------------------------------------
License Number | APRN.CNP.0041844
-----------------------------------------------------
License Number State | OH
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 163WP0807X
-----------------------------------------------------
Taxonomy Name | Child & Adolescent Psychiatric/Mental Health Registered Nurse
-----------------------------------------------------
License Number | APRN.CNP.0041844
-----------------------------------------------------
License Number State | OH
-----------------------------------------------------
Taxonomy #3
-----------------------------------------------------
Taxonomy Code | 163WP0809X
-----------------------------------------------------
Taxonomy Name | Adult Psychiatric/Mental Health Registered Nurse
-----------------------------------------------------
License Number | APRN.CNP.0041844
-----------------------------------------------------
License Number State | OH
-----------------------------------------------------