Provider Demographics
NPI:1902151095
Name:ROUX, LISSA NICOLE (FNP)
Entity type:Individual
Prefix:
First Name:LISSA
Middle Name:NICOLE
Last Name:ROUX
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 1:2595 CENTRAL AVE
Mailing Address - Street 2:
Mailing Address - City:MEMPHIS
Mailing Address - State:TN
Mailing Address - Zip Code:38104-5905
Mailing Address - Country:US
Mailing Address - Phone:901-260-8500
Mailing Address - Fax:901-260-8598
Practice Address - Street 1:2400 POPLAR AVE
Practice Address - Street 2:SUITE 501
Practice Address - City:MEMPHIS
Practice Address - State:TN
Practice Address - Zip Code:38112-3213
Practice Address - Country:US
Practice Address - Phone:901-701-2580
Practice Address - Fax:901-260-8449
Is Sole Proprietor?:No
Enumeration Date:2012-07-16
Last Update Date:2015-03-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSR881642163W00000X
TN16791363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No163W00000XNursing Service ProvidersRegistered Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN1529003Medicaid
TN1529003Medicaid