Provider Demographics
NPI:1154480408
Name:MCNIEL, LISSA MICHELLE (ND)
Entity Type:Individual
Prefix:DR
First Name:LISSA
Middle Name:MICHELLE
Last Name:MCNIEL
Suffix:
Gender:F
Credentials:ND
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:P.O. BOX 1442
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:OR
Mailing Address - Zip Code:97530
Mailing Address - Country:US
Mailing Address - Phone:541-773-1073
Mailing Address - Fax:
Practice Address - Street 1:3654C S PACIFIC HWY
Practice Address - Street 2:
Practice Address - City:MEDFORD
Practice Address - State:OR
Practice Address - Zip Code:97501-8922
Practice Address - Country:US
Practice Address - Phone:541-535-9210
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-12-06
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR1471175F00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes175F00000XOther Service ProvidersNaturopath
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR213135Medicare ID - Type UnspecifiedOMAP PROVIDER NUMBER