Provider Demographics
NPI:1487310488
Name:PIVIN, LISA A (RN, IBCLC)
Entity type:Individual
Prefix:MS
First Name:LISA
Middle Name:A
Last Name:PIVIN
Suffix:
Gender:F
Credentials:RN, IBCLC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4200 HAMPTON RD
Mailing Address - Street 2:
Mailing Address - City:CLEMMONS
Mailing Address - State:NC
Mailing Address - Zip Code:27012-9403
Mailing Address - Country:US
Mailing Address - Phone:207-890-9854
Mailing Address - Fax:
Practice Address - Street 1:4200 HAMPTON RD
Practice Address - Street 2:
Practice Address - City:CLEMMONS
Practice Address - State:NC
Practice Address - Zip Code:27012-9403
Practice Address - Country:US
Practice Address - Phone:843-509-2851
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-11-14
Last Update Date:2021-11-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCL-301320163WL0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WL0100XNursing Service ProvidersRegistered NurseLactation Consultant