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General NPI Number Information
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NPI Number | 1720031404
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Entity Type | Individual
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Provider Name | LISA DIANE FAIRWEATHER D.O.
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Gender | Female
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Dates
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Enumeration Date | 05/17/2006
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Last Update Date | 10/14/2010
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Provider Practice Location Address
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Address Line | 5601 BRIDGE ST. #324
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City | FT. WORTH
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State | TX
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Zip | 76112
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Country | US
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Telephone | 817-457-4646
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Fax | 817-492-7135
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Provider Business Mailing Address
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Address Line | 5601 BRIDGE ST. #324
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City | FT. WORTH
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State | TX
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Zip | 76112
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Country | US
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Telephone | 817-457-4646
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Fax | 817-492-7135
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 2084P0800X
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Taxonomy Name | Psychiatry Physician
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License Number | L6256
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License Number State | TX
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