Provider Demographics
NPI:1164033858
Name:LUSK, TESSA LYNN
Entity Type:Individual
Prefix:
First Name:TESSA
Middle Name:LYNN
Last Name:LUSK
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:PO BOX 183
Mailing Address - Street 2:
Mailing Address - City:BIM
Mailing Address - State:WV
Mailing Address - Zip Code:25021-0183
Mailing Address - Country:US
Mailing Address - Phone:304-470-2448
Mailing Address - Fax:
Practice Address - Street 1:57 GATEWOOD LN
Practice Address - Street 2:
Practice Address - City:BIM
Practice Address - State:WV
Practice Address - Zip Code:25021
Practice Address - Country:US
Practice Address - Phone:304-470-2448
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-08-14
Last Update Date:2022-04-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3747P1801XNursing Service Related ProvidersTechnicianPersonal Care Attendant