Provider Demographics
NPI:1215965074
Name:STEVENS, LISA (CNM)
Entity type:Individual
Prefix:
First Name:LISA
Middle Name:
Last Name:STEVENS
Suffix:
Gender:F
Credentials:CNM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10 SUNNYBROOK RD
Mailing Address - Street 2:
Mailing Address - City:RALEIGH
Mailing Address - State:NC
Mailing Address - Zip Code:27610-1808
Mailing Address - Country:US
Mailing Address - Phone:919-212-7000
Mailing Address - Fax:
Practice Address - Street 1:10 SUNNYBROOK RD
Practice Address - Street 2:
Practice Address - City:RALEIGH
Practice Address - State:NC
Practice Address - Zip Code:27610-1808
Practice Address - Country:US
Practice Address - Phone:919-212-7000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-06-29
Last Update Date:2022-12-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0024166990367A00000X
NC164367A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367A00000XPhysician Assistants & Advanced Practice Nursing ProvidersAdvanced Practice Midwife
Provider Identifiers
StateIdentifier IDID TypeIssuer
VACN3911OtherRAILROAD MEDICARE PTAN
VA210104OtherANTHEM
VA010293821Medicaid
VA10012208MOtherOPTIMA
VAC02245OtherMEDICARE PTAN
VA018694O45OtherMEDICARE PTAN