Basic Information
Provider Information | |||||||||
NPI: | 1578510970 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | TERRY | ||||||||
FirstName: | LISA | ||||||||
MiddleName: | ANN | ||||||||
NamePrefix: | MS. | ||||||||
NameSuffix: |   | ||||||||
Credential: | NP | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: | PEWITT | ||||||||
OtherFirstName: | LISA | ||||||||
OtherMiddleName: | GRISSOM | ||||||||
OtherNamePrefix: | MS. | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: | NP | ||||||||
OtherLastNameType: | 1 | ||||||||
Mailing Information | |||||||||
Address1: | 1453 HOPE WAY | ||||||||
Address2: |   | ||||||||
City: | MURFREESBORO | ||||||||
State: | TN | ||||||||
PostalCode: | 371293140 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 6158939390 | ||||||||
FaxNumber: | 6158934162 | ||||||||
Practice Location | |||||||||
Address1: | 1453 HOPE WAY | ||||||||
Address2: |   | ||||||||
City: | MURFREESBORO | ||||||||
State: | TN | ||||||||
PostalCode: | 371293140 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 6158939390 | ||||||||
FaxNumber: | 6158934162 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 05/30/2006 | ||||||||
LastUpdateDate: | 08/16/2022 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 08/16/2022 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LF0000X | APN0000006061 | TN | Y |   | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family |
ID Information
ID | Type | State | Issuer | Description | 3908318 | 05 | TN |   | MEDICAID |