Provider Demographics
NPI:1154832608
Name:MINOR, LISA ANN
Entity Type:Individual
Prefix:
First Name:LISA
Middle Name:ANN
Last Name:MINOR
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 1:1411 MARSHALL ST
Mailing Address - Street 2:
Mailing Address - City:MCMECHEN
Mailing Address - State:WV
Mailing Address - Zip Code:26040-1146
Mailing Address - Country:US
Mailing Address - Phone:304-233-4323
Mailing Address - Fax:
Practice Address - Street 1:1411 MARSHALL ST
Practice Address - Street 2:
Practice Address - City:MCMECHEN
Practice Address - State:WV
Practice Address - Zip Code:26040-1146
Practice Address - Country:US
Practice Address - Phone:304-233-4323
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-10-23
Last Update Date:2017-10-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV38100284893747P1801X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3747P1801XNursing Service Related ProvidersTechnicianPersonal Care Attendant
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV3810028489OtherPROVIDER ID