Provider Demographics
NPI:1871982157
Name:RUTHERFORD, LISA MARIE (NP)
Entity type:Individual
Prefix:
First Name:LISA
Middle Name:MARIE
Last Name:RUTHERFORD
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:LISA
Other - Middle Name:
Other - Last Name:WINTERS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 751803
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28275-1803
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2085 FRONTIS PLAZA BLVD
Practice Address - Street 2:
Practice Address - City:WINSTON SALEM
Practice Address - State:NC
Practice Address - Zip Code:27103-5614
Practice Address - Country:US
Practice Address - Phone:704-316-4136
Practice Address - Fax:704-316-9208
Is Sole Proprietor?:No
Enumeration Date:2015-01-09
Last Update Date:2021-11-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC5007387363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner