Provider Demographics
NPI:1154337871
Name:CORN, LISA (FNP)
Entity type:Individual
Prefix:
First Name:LISA
Middle Name:
Last Name:CORN
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 601692
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28260-1692
Mailing Address - Country:US
Mailing Address - Phone:704-512-6240
Mailing Address - Fax:704-512-6241
Practice Address - Street 1:4525 CAMERON VALLEY PKWY
Practice Address - Street 2:STE 1500
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28211-3546
Practice Address - Country:US
Practice Address - Phone:704-512-6240
Practice Address - Fax:704-512-6241
Is Sole Proprietor?:No
Enumeration Date:2006-08-01
Last Update Date:2012-02-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC200907363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC7004146Medicaid
NC2599136XMedicare PIN
NC2599136BMedicare ID - Type Unspecified
NC2599136JMedicare PIN
NC7004146Medicaid
NC2599136HMedicare PIN
NC2599136EMedicare PIN