Provider Demographics
NPI:1104591098
Name:WHITNUM, LISA D (PMHNP-BC)
Entity type:Individual
Prefix:
First Name:LISA
Middle Name:D
Last Name:WHITNUM
Suffix:
Gender:
Credentials:PMHNP-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10900 NUCKOLS RD STE 100
Mailing Address - Street 2:
Mailing Address - City:GLEN ALLEN
Mailing Address - State:VA
Mailing Address - Zip Code:23060-9277
Mailing Address - Country:US
Mailing Address - Phone:804-207-6737
Mailing Address - Fax:
Practice Address - Street 1:10900 NUCKOLS RD STE 100
Practice Address - Street 2:
Practice Address - City:GLEN ALLEN
Practice Address - State:VA
Practice Address - Zip Code:23060-9277
Practice Address - Country:US
Practice Address - Phone:804-207-6737
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-08-12
Last Update Date:2025-05-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0001191786163WP0808X
VA0024182387363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
No163WP0808XNursing Service ProvidersRegistered NursePsychiatric/Mental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA30016690600003Medicaid