Provider Demographics
NPI:1902899867
Name:WHITLEY, LISA ERIN (PMHS)
Entity type:Individual
Prefix:
First Name:LISA
Middle Name:ERIN
Last Name:WHITLEY
Suffix:
Gender:F
Credentials:PMHS
Other - Prefix:
Other - First Name:LISA
Other - Middle Name:ERIN
Other - Last Name:WHITLEY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:129 WOODSON ST
Mailing Address - Street 2:
Mailing Address - City:SALISBURY
Mailing Address - State:NC
Mailing Address - Zip Code:28144-3255
Mailing Address - Country:US
Mailing Address - Phone:704-636-5576
Mailing Address - Fax:704-636-1755
Practice Address - Street 1:129 WOODSON ST
Practice Address - Street 2:
Practice Address - City:SALISBURY
Practice Address - State:NC
Practice Address - Zip Code:28144-3255
Practice Address - Country:US
Practice Address - Phone:704-636-5576
Practice Address - Fax:704-636-1755
Is Sole Proprietor?:No
Enumeration Date:2005-08-25
Last Update Date:2018-11-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC5000717363L00000X, 363LP0200X, 363LP0808X, 363LP1700X, 363LP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPediatrics
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
No363LP1700XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPerinatal
No363LP2300XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPrimary Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC7005991Medicaid