Provider Demographics
NPI:1063758142
Name:DELACRUZ, LISA M (PNP)
Entity type:Individual
Prefix:
First Name:LISA
Middle Name:M
Last Name:DELACRUZ
Suffix:
Gender:F
Credentials:PNP
Other - Prefix:
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Other - Credentials:
Mailing Address - Street 1:PO BOX 60447
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28260-0447
Mailing Address - Country:US
Mailing Address - Phone:704-384-1440
Mailing Address - Fax:704-384-1452
Practice Address - Street 1:14215 BALLANTYNE CORPORATE PL
Practice Address - Street 2:SUITE 130
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28277-3670
Practice Address - Country:US
Practice Address - Phone:704-384-1950
Practice Address - Fax:704-384-1955
Is Sole Proprietor?:No
Enumeration Date:2012-12-18
Last Update Date:2020-10-28
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
OH20122290363LP0200X
NC5006132363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No363LP0200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPediatrics