Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
N | 363LF0000X | Nurse Practitioner - Family Medicine | 5004669 | NC |
Y | 363LP0808X | Nurse Practitioner - Psychiatric/Mental Health | 5004669 | NC |
NPI | 1033434519 |
---|---|
Provider Name | Mrs. Lisa Marie Suddreth |
First Address | Denver, NC 28037 |
Second Address | Gastonia, NC 28054-2192 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 29/03/2010 |
Last Update Date | 17/03/2018 |