Provider Demographics
NPI:1386959450
Name:ROYSTON, LISA ANN
Entity type:Individual
Prefix:MRS
First Name:LISA
Middle Name:ANN
Last Name:ROYSTON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2308 W 21ST ST
Mailing Address - Street 2:
Mailing Address - City:PANAMA CITY
Mailing Address - State:FL
Mailing Address - Zip Code:32405-2424
Mailing Address - Country:US
Mailing Address - Phone:850-763-1442
Mailing Address - Fax:
Practice Address - Street 1:2308 W 21ST ST
Practice Address - Street 2:
Practice Address - City:PANAMA CITY
Practice Address - State:FL
Practice Address - Zip Code:32405-2424
Practice Address - Country:US
Practice Address - Phone:850-763-1442
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-08-13
Last Update Date:2010-08-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172V00000XOther Service ProvidersCommunity Health Worker
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL673364696Medicaid