Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 363LN0005X | Nurse Practitioner - Neonatal (Critical Care) | 18835 | SC |
N | 363LN0005X | Nurse Practitioner - Neonatal (Critical Care) | 5005582 | NC |
NPI | 1063770147 |
---|---|
Provider Name | Mrs. Tyner Leigh Ray Lollis |
First Address | Charlotte, NC 28275-1461 |
Second Address | Charleston, SC 29425-4210 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 26/04/2012 |
Last Update Date | 22/05/2019 |