Provider Demographics
NPI:1083013353
Name:MCCLURE, LISA MARIE (FNP-C)
Entity Type:Individual
Prefix:MS
First Name:LISA
Middle Name:MARIE
Last Name:MCCLURE
Suffix:
Gender:F
Credentials:FNP-C
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Other - First Name:
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Other - Credentials:
Mailing Address - Street 1:4605 MACCORKLE AVE SW
Mailing Address - Street 2:
Mailing Address - City:SOUTH CHARLESTON
Mailing Address - State:WV
Mailing Address - Zip Code:25309-1311
Mailing Address - Country:US
Mailing Address - Phone:304-414-4800
Mailing Address - Fax:304-414-4801
Practice Address - Street 1:500 POPLAR ST
Practice Address - Street 2:SUITE 202
Practice Address - City:SOUTH CHARLESTON
Practice Address - State:WV
Practice Address - Zip Code:25309-1474
Practice Address - Country:US
Practice Address - Phone:304-346-2121
Practice Address - Fax:304-346-2176
Is Sole Proprietor?:No
Enumeration Date:2014-08-22
Last Update Date:2021-12-29
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
WVAPRN76097NP363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
WVB441OtherGROUP MEDICARE
WV3810027776Medicaid
WV3810024049OtherGROUP MEDICAID
WV3810027776Medicaid