Provider Demographics
NPI:1225634736
Name:SHAMBLIN, LISA
Entity Type:Individual
Prefix:
First Name:LISA
Middle Name:
Last Name:SHAMBLIN
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 1:11517 ELK RIVER RD N
Mailing Address - Street 2:
Mailing Address - City:CLENDENIN
Mailing Address - State:WV
Mailing Address - Zip Code:25045-6206
Mailing Address - Country:US
Mailing Address - Phone:304-389-9400
Mailing Address - Fax:304-471-2488
Practice Address - Street 1:4510 PENNSYLVANIA AVE
Practice Address - Street 2:
Practice Address - City:CHARLESTON
Practice Address - State:WV
Practice Address - Zip Code:25302-4835
Practice Address - Country:US
Practice Address - Phone:304-965-9081
Practice Address - Fax:304-471-2488
Is Sole Proprietor?:No
Enumeration Date:2020-12-09
Last Update Date:2020-12-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV30302163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse