Basic Information
| Provider Information | |||||||||
| NPI: | 1619918521 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | DEMENT | ||||||||
| FirstName: | LISA | ||||||||
| MiddleName: | ANNETTE | ||||||||
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| Credential: | FNP | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 1100 | ||||||||
| Address2: | |||||||||
| City: | MAGEE | ||||||||
| State: | MS | ||||||||
| PostalCode: | 391111100 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6018496440 | ||||||||
| FaxNumber: | 6018497557 | ||||||||
| Practice Location | |||||||||
| Address1: | 40128 HAMILTON RD | ||||||||
| Address2: | |||||||||
| City: | HAMILTON | ||||||||
| State: | MS | ||||||||
| PostalCode: | 397469686 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6623692455 | ||||||||
| FaxNumber: | 6623192125 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/10/2006 | ||||||||
| LastUpdateDate: | 07/08/2007 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | X | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LF0000X | R803971 | MS | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family |
ID Information
| ID | Type | State | Issuer | Description | 00123535 | 05 | MS | MEDICAID |