Provider Demographics
NPI:1083938989
Name:PROUGH, LISA NICOLE (LPN)
Entity Type:Individual
Prefix:MISS
First Name:LISA
Middle Name:NICOLE
Last Name:PROUGH
Suffix:
Gender:F
Credentials:LPN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:612 E MAIN ST # R
Mailing Address - Street 2:
Mailing Address - City:ROARING SPRING
Mailing Address - State:PA
Mailing Address - Zip Code:16673-1320
Mailing Address - Country:US
Mailing Address - Phone:814-330-9591
Mailing Address - Fax:
Practice Address - Street 1:201 CHESTNUT AVE
Practice Address - Street 2:
Practice Address - City:ALTOONA
Practice Address - State:PA
Practice Address - Zip Code:16601-4927
Practice Address - Country:US
Practice Address - Phone:814-946-5411
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-03-22
Last Update Date:2010-03-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAPN283072164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse