Provider Demographics
NPI:1487609871
Name:BAILEY, LISA M (FNP)
Entity type:Individual
Prefix:MRS
First Name:LISA
Middle Name:M
Last Name:BAILEY
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:
Other - First Name:LISA
Other - Middle Name:M
Other - Last Name:CHANCELLOR
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:CNP
Mailing Address - Street 1:415 S 28TH AVE
Mailing Address - Street 2:
Mailing Address - City:HATTIESBURG
Mailing Address - State:MS
Mailing Address - Zip Code:39401-7246
Mailing Address - Country:US
Mailing Address - Phone:601-261-1500
Mailing Address - Fax:601-579-5240
Practice Address - Street 1:7148 U S HIGHWAY 98
Practice Address - Street 2:SUITE 101
Practice Address - City:HATTIESBURG
Practice Address - State:MS
Practice Address - Zip Code:39402-8577
Practice Address - Country:US
Practice Address - Phone:601-261-1500
Practice Address - Fax:601-296-7549
Is Sole Proprietor?:No
Enumeration Date:2006-05-23
Last Update Date:2020-07-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSR669482363L00000X, 363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS00115017Medicaid
MS2283275OtherUNITED HEALTHCARE
MS4846774OtherCIGNA
MS7689898OtherAETNA
MS7689898OtherAETNA
MS302I504923Medicare PIN
MS2283275OtherUNITED HEALTHCARE
MS7689898OtherAETNA