MEDICARE: MRS. LISA ANN CULLISON APRN, PMHNP-BC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	363LP0808X	Psychiatric/Mental Health Nurse Practitioner	APRN.CNP.0041844	OH

General Provider Information

NPI Number	:	1063351211
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MRS. LISA ANN CULLISON APRN, PMHNP-BC

Provider Business Mailing Address
First Line	:	19567 HARBLE RD
Second Line	:
City	:	LOGAN
State	:	OH
Zip	:	43138-7538
Country	:	US
Telephone Number	:	386-453-4105
Fax Number	:

Provider Business Practice Location Address
First Line	:	19567 HARBLE RD
Second Line	:
City	:	LOGAN
State	:	OH
Zip	:	43138-7538
Country	:	US
Telephone Number	:	386-453-4105
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	03/25/2026
Last Update Date	:	04/14/2026

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