Provider Demographics
NPI:1114609666
Name:STEWART, LISA
Entity Type:Individual
Prefix:
First Name:LISA
Middle Name:
Last Name:STEWART
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 1:9665 NATIONAL RD
Mailing Address - Street 2:
Mailing Address - City:VALLEY GROVE
Mailing Address - State:WV
Mailing Address - Zip Code:26060-8966
Mailing Address - Country:US
Mailing Address - Phone:304-312-4923
Mailing Address - Fax:
Practice Address - Street 1:9665 NATIONAL RD
Practice Address - Street 2:
Practice Address - City:VALLEY GROVE
Practice Address - State:WV
Practice Address - Zip Code:26060-8966
Practice Address - Country:US
Practice Address - Phone:304-312-4923
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-08-03
Last Update Date:2023-08-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172V00000XOther Service ProvidersCommunity Health Worker