Provider Demographics
NPI:1093138513
Name:NULL, LISA
Entity Type:Individual
Prefix:MRS
First Name:LISA
Middle Name:
Last Name:NULL
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3790 FOREST GREEN BLVD NW
Mailing Address - Street 2:
Mailing Address - City:BALTIMORE
Mailing Address - State:OH
Mailing Address - Zip Code:43105-9553
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:340 WAGGONER RD
Practice Address - Street 2:
Practice Address - City:REYNOLDSBURG
Practice Address - State:OH
Practice Address - Zip Code:43068-9707
Practice Address - Country:US
Practice Address - Phone:614-501-5600
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-02-04
Last Update Date:2014-02-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH273526163WS0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WS0200XNursing Service ProvidersRegistered NurseSchool