Provider Demographics
NPI:1104254473
Name:FETTERS, LISA DAWN (NP)
Entity type:Individual
Prefix:
First Name:LISA
Middle Name:DAWN
Last Name:FETTERS
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:150 KINGSLEY LN
Mailing Address - Street 2:
Mailing Address - City:NORFOLK
Mailing Address - State:VA
Mailing Address - Zip Code:23505-4602
Mailing Address - Country:US
Mailing Address - Phone:757-484-5900
Mailing Address - Fax:757-483-3371
Practice Address - Street 1:150 KINGSLEY LN
Practice Address - Street 2:
Practice Address - City:NORFOLK
Practice Address - State:VA
Practice Address - Zip Code:23505-4602
Practice Address - Country:US
Practice Address - Phone:757-484-5900
Practice Address - Fax:757-483-3371
Is Sole Proprietor?:No
Enumeration Date:2013-10-24
Last Update Date:2013-11-06
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
VA0110004274363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant