Basic Information
Provider Information | |||||||||
NPI: | 1891011235 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | JESSEE | ||||||||
FirstName: | LISA | ||||||||
MiddleName: | MARIE | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | FNP | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: | LUNDY | ||||||||
OtherFirstName: | LISA | ||||||||
OtherMiddleName: | MARIE | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: | FNP | ||||||||
OtherLastNameType: | 1 | ||||||||
Mailing Information | |||||||||
Address1: | PO BOX 9 | ||||||||
Address2: |   | ||||||||
City: | KINGSPORT | ||||||||
State: | TN | ||||||||
PostalCode: | 376620009 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 4238572066 | ||||||||
FaxNumber: | 4238572070 | ||||||||
Practice Location | |||||||||
Address1: | 1754 US HIGHWAY 23 N | ||||||||
Address2: |   | ||||||||
City: | WEBER CITY | ||||||||
State: | VA | ||||||||
PostalCode: | 242907071 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2763865980 | ||||||||
FaxNumber: | 2763869387 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 04/09/2010 | ||||||||
LastUpdateDate: | 07/09/2020 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 07/09/2020 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363L00000X | 0024168750 | VA | Y |   | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner |   |
ID Information
ID | Type | State | Issuer | Description | 1891011235 | 05 | VA |   | MEDICAID | 1520727 | 05 | TN |   | MEDICAID |